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Men's Health (https, //urology.weillcornell. org /sites /default /files /aua Benign Prostatic Hyperplasia symptom score-web.pdf) and determine appropriate treat Benign prostatic hyperplasia (BPH) is a histologic diagnosis ment and response. characterized by smooth muscle and epithelial cell prolifera- All patients with LUTS should undergo digital rectal tion in the prostate's transition (periurethral) zone, which can examination to assess prostate size and contour, rectal sphinc- lead to urethral compression and subsequent impaired empty ter tone, and perineal sensation. Larger prostate size suggests ing of the bladder, bladder distention, and detrusor muscle increased risk for progression ofLUTS. Prostate tenderness or dysfunction. The prevalence of BPH increases dramatically bogginess suggests prostatitis. A prostate nodule raises con with age. BPH frequently causes lower urinary tract symptoms (LUTS) but can also be asymptomatic. LUTS can be divided cern for prostate cancer. Abnormal rectal tone and perineal sensation suggests an underlying neurologic disorder. The into obstructive voiding or bladder storage (irritative) symp- AUA recommends performing urinalysis in all patients with toms. Obstructive voiding symptoms include difficulty initiat LUTS. In addition, a PSA Ievel should be obtained in patients ing urination, weak urinary stream, dribbling, straining to who meet criteria for PSA based prostate cancer screening and void, urinary hesitancy, and incomplete bladder emptying. who desire screening (see Routine Care of the Healthy Patient). Bladder storage symptoms include nocturia, dysuria, and uri The goal of treating LUTS secondary to BPH is symptom nary frequency and urgency. LUTS is not specific to BPH (Table 41). Patients should be amelioration. Active surveillance is recommended for patients asked about prior sexually transmitted infections, urethral with mild symptoms (AUA-SI score <8) and those with more trauma, and urologic procedures. A comprehensive assess severe disease (AUA-SI >8) who are not bothered by their ment of both prescription and over the-counter medications symptoms. Lifestyle modifications, including minimizing should be performed. Anticholinergics (antihistamines and fluid intake around bedtime and avoiding bladder irritants, tricyclic antidepressants) can lead to detrusor muscle dysfunc- such as caffeine and alcohol, should be offered to all patients. tion with decreased bladder contractility. Decongestants (sym- Patients with bladder storage symptoms may benefit from pathomimetics) bind to o receptors, which can lead to bladder scheduled voiding and pelvic floor muscle strengthening outlet obstruction. Opioid use can also result in urinary reten exercises. Symptoms should be reassessed annually using tion. Lifestyle factors can contribute to LUTS, and fluid intake thE AUA SI. and consumption of bladder irritants, including alcohol, caf In patients with bothersome moderate to severe symp feine, and acidic and spicy foods, should be determined. The toms (AUA SI score >B), pharmacotherapy is recommended. AUA Symptom Index (AUA-SI), a validated seven item ques Therapeutic response can be monitored using the AUA SI; a tionnaire, can be used to objectively assess LUTS severity decrease in AUA-SI score by 3 or more points represents clini cally significant improvement. TABLE 41. Causes of Lower UrinaryTract Symptoms in Men cr Blockers are considered first line pharmacotherapy and function by promoting smooth muscle relaxation; they do Benign prostatic hyperplasia not affect disease progression. Symptom improvement is gen Med ications (diuretics, anticholinergics, sympathomimetics, antihistamines, opioids) erally seen within 48 hours of initiation, with maximal improvement noted within several weeks. Nonspecific Bladder irritants (caffeine, alcohol, spicy and acid-rich foods, carbonated beverages) o-blockers (alfuzosin, doxazosin, prazosin, and terazosin) Ove ractive bladder/d etrusor dysf u nction block both drA prostate receptors and cx," smooth muscle receptors in blood vessels and can be associated with ortho Urethral strictures stasis and lightheadedness. These agents should be started at Bladder stones low doses and slowly titrated upward. Silodosin and tamsulo- Urinary tract infections sin, which are c,,1-specific cr-blockers, are less likely to cause Urethritis orthostasis and do not require dose titration; however, they are Prostatitis more likely to cause retrograde ejaculation. Ifcataract surgery Prostate cancer is planned, initiation of o,-blocker therapy should be delayed owing to possible development of intraoperative floppy iris Bladder cancer syndrome, a condition characterized by impaired pupil dila Polyd ipsia tion and increased risk for perioperative complications. Diabetes mellitus Caution should be exercised with concomitant PDE-S inhibi Hypercalcemia tor use owing to the possibility of hypotension, although Spinal cord injury PDE 5 inhibitors, especially dailyuse oltadalafil, may improve Parkinson disease LUTS and be a reasonable option in concomitant BPH and

(https, //urology.weillcornell. org /sites /default /files /aua Benign Prostatic Hyperplasia symptom score-web.pdf) and determine appropriate treat Benign prostatic hyperplasia (BPH) is a histologic diagnosis ment and response. characterized by smooth muscle and epithelial cell prolifera- All patients with LUTS should undergo digital rectal tion in the prostate's transition (periurethral) zone, which can examination to assess prostate size and contour, rectal sphinc- lead to urethral compression and subsequent impaired empty ter tone, and perineal sensation. Larger prostate size suggests ing of the bladder, bladder distention, and detrusor muscle increased risk for progression ofLUTS. Prostate tenderness or dysfunction. The prevalence of BPH increases dramatically bogginess suggests prostatitis. A prostate nodule raises con with age. BPH frequently causes lower urinary tract symptoms (LUTS) but can also be asymptomatic. LUTS can be divided cern for prostate cancer. Abnormal rectal tone and perineal sensation suggests an underlying neurologic disorder. The into obstructive voiding or bladder storage (irritative) symp- AUA recommends performing urinalysis in all patients with toms. Obstructive voiding symptoms include difficulty initiat LUTS. In addition, a PSA Ievel should be obtained in patients ing urination, weak urinary stream, dribbling, straining to who meet criteria for PSA based prostate cancer screening and void, urinary hesitancy, and incomplete bladder emptying. who desire screening (see Routine Care of the Healthy Patient). Bladder storage symptoms include nocturia, dysuria, and uri The goal of treating LUTS secondary to BPH is symptom nary frequency and urgency. LUTS is not specific to BPH (Table 41). Patients should be amelioration. Active surveillance is recommended for patients asked about prior sexually transmitted infections, urethral with mild symptoms (AUA-SI score <8) and those with more trauma, and urologic procedures. A comprehensive assess severe disease (AUA-SI >8) who are not bothered by their ment of both prescription and over the-counter medications symptoms. Lifestyle modifications, including minimizing should be performed. Anticholinergics (antihistamines and fluid intake around bedtime and avoiding bladder irritants, tricyclic antidepressants) can lead to detrusor muscle dysfunc- such as caffeine and alcohol, should be offered to all patients. tion with decreased bladder contractility. Decongestants (sym- Patients with bladder storage symptoms may benefit from pathomimetics) bind to o receptors, which can lead to bladder scheduled voiding and pelvic floor muscle strengthening outlet obstruction. Opioid use can also result in urinary reten exercises. Symptoms should be reassessed annually using tion. Lifestyle factors can contribute to LUTS, and fluid intake thE AUA SI. and consumption of bladder irritants, including alcohol, caf In patients with bothersome moderate to severe symp feine, and acidic and spicy foods, should be determined. The toms (AUA SI score >B), pharmacotherapy is recommended. AUA Symptom Index (AUA-SI), a validated seven item ques Therapeutic response can be monitored using the AUA SI; a tionnaire, can be used to objectively assess LUTS severity decrease in AUA-SI score by 3 or more points represents clini cally significant improvement. TABLE 41. Causes of Lower UrinaryTract Symptoms in Men cr Blockers are considered first line pharmacotherapy and function by promoting smooth muscle relaxation; they do Benign prostatic hyperplasia not affect disease progression. Symptom improvement is gen Med ications (diuretics, anticholinergics, sympathomimetics, antihistamines, opioids) erally seen within 48 hours of initiation, with maximal improvement noted within several weeks. Nonspecific Bladder irritants (caffeine, alcohol, spicy and acid-rich foods, carbonated beverages) o-blockers (alfuzosin, doxazosin, prazosin, and terazosin) Ove ractive bladder/d etrusor dysf u nction block both drA prostate receptors and cx," smooth muscle receptors in blood vessels and can be associated with ortho Urethral strictures stasis and lightheadedness. These agents should be started at Bladder stones low doses and slowly titrated upward. Silodosin and tamsulo- Urinary tract infections sin, which are c,,1-specific cr-blockers, are less likely to cause Urethritis orthostasis and do not require dose titration; however, they are Prostatitis more likely to cause retrograde ejaculation. Ifcataract surgery Prostate cancer is planned, initiation of o,-blocker therapy should be delayed owing to possible development of intraoperative floppy iris Bladder cancer syndrome, a condition characterized by impaired pupil dila Polyd ipsia tion and increased risk for perioperative complications. Diabetes mellitus Caution should be exercised with concomitant PDE-S inhibi Hypercalcemia tor use owing to the possibility of hypotension, although Spinal cord injury PDE 5 inhibitors, especially dailyuse oltadalafil, may improve Parkinson disease LUTS and be a reasonable option in concomitant BPH and Neurogenic bladder erectile dysfunction. 5o Reductase inhibitors (dutasteride and finasteride) Obstructive sleep apnea are considered second line therapy for BPH related LUTS and

Neurogenic bladder erectile dysfunction. 5o Reductase inhibitors (dutasteride and finasteride) Obstructive sleep apnea are considered second line therapy for BPH related LUTS and 51

Men's Health are effective only in patients with an enlarged prostate. TABLE 42. Empiric AntimicrobialTherapy for Epididymitis So-Reductase inhibitors function by preventing the conver, and Epididymo-orchitis sion of testosterone to dihydroxytestosterone, inhibiting pros- Patient Group Therapy tate growth. These agents must be taken for up to 6 months Age <35 y lntramuscular ceftriaxone and before symptomatic improvement may be seen. In patients oral doxycycline with LUTS who have an enlarged prostate, combining a Age >35 y Oral levofloxacin 5o reductase inhibitor with an cr blocker appears to be more Age >35 y and at risk for lntramuscular ceft riaxone and effective than either agent alone. Side effects of 5a reductase chlamydia or gonococcal oral doxycycline inhibitors include decreased libido, erectile dysfunction, infection breast tenderness, and S/necomastia. Although several trials All men who practice lntramuscu lar ceftriaxone and have shown reduced incidence of low-grade prostate cancer insertive anal intercourse oral levofloxacin with So-reductase inhibitors, there appears to be a slight increase in high-grade prostate cancer. undergo imaging studies and instead be directly referred for Antimuscarinic agents, such as trospium, oxybutynin, immediate exploratory surgery because surgical delay reduces and tolterodine, can be used to treat bladder storage symptoms the probability of testicular viability. by relaxing bladder detrusor muscles. These are generally not Epididymitis is usually secondary to infection: when used as monotherapy but instead in combination with other infection spreads to the adjacent testis, it is termed epididymo agents. orchitis. Both conditions typically cause unilateral scrotal pain Saw palmetto is frequently used to treat LUTS secondary ofgradual onset that worsens over a period ofdays. In younger to BPH but lacks data supporting its efficacy. patients (age <35 years) , Chlamydia trochomotis and Neisserio Surgical treatment for LUTS secondary to BPH, most gonorrhoeae are the most commonly implicated pathogens. In commonly transurethral resection of the prostate, is usually men older than 35 years and those at low risk lor sexually reserved for individuals who do not respond to pharmaco- transmitted infections, colonic bacteria, such as Escherichia therapy or develop BPH complications, such as urinary reten coli, are the most common pathogens. Examination reveals tion or persistent gross hematuria. tenderness and swelling of involved structures. Pain may be XEY POITTS relieved with scrotal elevation. Urinalysis and culture should . All patients with lower urinary tract symptoms should be obtained in all patients, as well as testing for sexually trans

are effective only in patients with an enlarged prostate. TABLE 42. Empiric AntimicrobialTherapy for Epididymitis So-Reductase inhibitors function by preventing the conver, and Epididymo-orchitis sion of testosterone to dihydroxytestosterone, inhibiting pros- Patient Group Therapy tate growth. These agents must be taken for up to 6 months Age <35 y lntramuscular ceftriaxone and before symptomatic improvement may be seen. In patients oral doxycycline with LUTS who have an enlarged prostate, combining a Age >35 y Oral levofloxacin 5o reductase inhibitor with an cr blocker appears to be more Age >35 y and at risk for lntramuscular ceft riaxone and effective than either agent alone. Side effects of 5a reductase chlamydia or gonococcal oral doxycycline inhibitors include decreased libido, erectile dysfunction, infection breast tenderness, and S/necomastia. Although several trials All men who practice lntramuscu lar ceftriaxone and have shown reduced incidence of low-grade prostate cancer insertive anal intercourse oral levofloxacin with So-reductase inhibitors, there appears to be a slight increase in high-grade prostate cancer. undergo imaging studies and instead be directly referred for Antimuscarinic agents, such as trospium, oxybutynin, immediate exploratory surgery because surgical delay reduces and tolterodine, can be used to treat bladder storage symptoms the probability of testicular viability. by relaxing bladder detrusor muscles. These are generally not Epididymitis is usually secondary to infection: when used as monotherapy but instead in combination with other infection spreads to the adjacent testis, it is termed epididymo agents. orchitis. Both conditions typically cause unilateral scrotal pain Saw palmetto is frequently used to treat LUTS secondary ofgradual onset that worsens over a period ofdays. In younger to BPH but lacks data supporting its efficacy. patients (age <35 years) , Chlamydia trochomotis and Neisserio Surgical treatment for LUTS secondary to BPH, most gonorrhoeae are the most commonly implicated pathogens. In commonly transurethral resection of the prostate, is usually men older than 35 years and those at low risk lor sexually reserved for individuals who do not respond to pharmaco- transmitted infections, colonic bacteria, such as Escherichia therapy or develop BPH complications, such as urinary reten coli, are the most common pathogens. Examination reveals tion or persistent gross hematuria. tenderness and swelling of involved structures. Pain may be XEY POITTS relieved with scrotal elevation. Urinalysis and culture should . All patients with lower urinary tract symptoms should be obtained in all patients, as well as testing for sexually trans undergo a digital rectal examination to assess prostate mitted infections when suspicion is high. Imaging is usually size and contour, rectal sphincter tone, and perineal not necessary. Treatment consists of empiric antimicrobial therapy directed toward the most likely pathogen (Table 42). sensation. Conservative measures include scrotal elevation, NSAIDs, and . cr-Blockers are considered first line pharmacotherapy rest. for benign prostatic hyperplasia; combining a Other causes of acute testicular and scrotal pain are Scr-reductase inhibitor with an o blocker appears to be described in Table 43. more effective than either agent alone. xIY POtXrt o Testicular torsion presents as acute, unilateral, severe Acute Testicular and Scrotal Pain scrotal pain and swelling with an elevated testis on Evaluation of acute testicular and scrotal pain should begin examination and absent cremasteric reflex; it is a surgi- with a concise history focusing on pain characteristics, associ cal emergency. ated symptoms, trauma history previous urologic disorders, . Epididymitis and epididymo-orchitis are treated with and sexual history followed by a focused genitourinary empiric antimicrobial therapy directed toward the most examination. likely pathogen. Testicular torsion is the most important diagnosis to rule out initially. Although it is most common in younger men, it can occur at any age. Testicular torsion involves twisting of the spermatic cord structures, leading to ischemia and eventual Hyd rocele, Va ricocele, and infarction olthe testis. It is most commonly characterized by Epididymal Cyst acute onset ofsevere pain in one testis that rapidly progresses Hydroceles form when fluid accumulates within the space in severity over a period of hours and may be accompanied by befween the visceral and parietal Iayers of the tunica vaginalis nausea and vomiting. Examination findings include an exqui- (Figure g). The suspected etiologr is an imbalance between sitely tender and swollen testis that is elevated with erythema fluid secretion and reabsorption by the tunica vaginalis. of the overlying scrotal skin. The cremasteric reflex, testicular Symptoms include scrotal swelling and pain. On scrotal elevation in response to stroking the inner thigh, is typicaily transillumination, light shines through the scrotum. Asympto absent. If testicular torsion is suspected, patients should not matic hydroceles require no intervention, whereas patients with

undergo a digital rectal examination to assess prostate mitted infections when suspicion is high. Imaging is usually size and contour, rectal sphincter tone, and perineal not necessary. Treatment consists of empiric antimicrobial therapy directed toward the most likely pathogen (Table 42). sensation. Conservative measures include scrotal elevation, NSAIDs, and . cr-Blockers are considered first line pharmacotherapy rest. for benign prostatic hyperplasia; combining a Other causes of acute testicular and scrotal pain are Scr-reductase inhibitor with an o blocker appears to be described in Table 43. more effective than either agent alone. xIY POtXrt o Testicular torsion presents as acute, unilateral, severe Acute Testicular and Scrotal Pain scrotal pain and swelling with an elevated testis on Evaluation of acute testicular and scrotal pain should begin examination and absent cremasteric reflex; it is a surgi- with a concise history focusing on pain characteristics, associ cal emergency. ated symptoms, trauma history previous urologic disorders, . Epididymitis and epididymo-orchitis are treated with and sexual history followed by a focused genitourinary empiric antimicrobial therapy directed toward the most examination. likely pathogen. Testicular torsion is the most important diagnosis to rule out initially. Although it is most common in younger men, it can occur at any age. Testicular torsion involves twisting of the spermatic cord structures, leading to ischemia and eventual Hyd rocele, Va ricocele, and infarction olthe testis. It is most commonly characterized by Epididymal Cyst acute onset ofsevere pain in one testis that rapidly progresses Hydroceles form when fluid accumulates within the space in severity over a period of hours and may be accompanied by befween the visceral and parietal Iayers of the tunica vaginalis nausea and vomiting. Examination findings include an exqui- (Figure g). The suspected etiologr is an imbalance between sitely tender and swollen testis that is elevated with erythema fluid secretion and reabsorption by the tunica vaginalis. of the overlying scrotal skin. The cremasteric reflex, testicular Symptoms include scrotal swelling and pain. On scrotal elevation in response to stroking the inner thigh, is typicaily transillumination, light shines through the scrotum. Asympto absent. If testicular torsion is suspected, patients should not matic hydroceles require no intervention, whereas patients with 52

Men's Health TABLE 43. Other Causes of AcuteTesticular and Scrotal Pain Cause Presentation Diagnosis Treatment Additional lnformation Torsion of Similar presentation to Examination (although lmmediate urology Self-limited condition; appendix testis testicular torsion often diagnosed during referral for evaluation testicular torsion must and appendix surgical exploration) be ruled out "Blue dot sign" on examina- Surgery often required epididymis tion (ischemic structures seen to rule outtesticular beneath scrotal skin) torsion Testicular Typically presents as a painless Examination Surgery Most common malignancy testicular mass; in 'l 5% of cases, malignancy in men presents with either acute onset Ultrasonography Chemotherapy aged <40 y or indolent dull, achy pain Tumor markers (o-fetoprotein, B-human Firm, fixed, palpable mass on chorionic gonadotropin, surface of testis lactate dehyd rogenase) Viral orchitis (e.9., Bilateral testicular pain and Examination Analgesia with NSAIDs Occu rs in 20"/"-30"/" of mumps, rubella) swelling men with mumps Serologies Orchitis without epididymitis should raise concern {or mumps Nephrolithiasis Pain typically starts in flank and Urinalysis Encourage oral intake of Presence of fever or radiates into anterior lower fluids evidence of systemic lmaging abdomen and groin/scrotum as illness should raise (ultrasonography, or Analgesia with NSAIDs stone migrates into lower ureter concern for in{ected noncontrast helical CT) Tamsulosin stone Examination of scrotum and testes are normal Larger stones may require urologic extraction

TABLE 43. Other Causes of AcuteTesticular and Scrotal Pain Cause Presentation Diagnosis Treatment Additional lnformation Torsion of Similar presentation to Examination (although lmmediate urology Self-limited condition; appendix testis testicular torsion often diagnosed during referral for evaluation testicular torsion must and appendix surgical exploration) be ruled out "Blue dot sign" on examina- Surgery often required epididymis tion (ischemic structures seen to rule outtesticular beneath scrotal skin) torsion Testicular Typically presents as a painless Examination Surgery Most common malignancy testicular mass; in 'l 5% of cases, malignancy in men presents with either acute onset Ultrasonography Chemotherapy aged <40 y or indolent dull, achy pain Tumor markers (o-fetoprotein, B-human Firm, fixed, palpable mass on chorionic gonadotropin, surface of testis lactate dehyd rogenase) Viral orchitis (e.9., Bilateral testicular pain and Examination Analgesia with NSAIDs Occu rs in 20"/"-30"/" of mumps, rubella) swelling men with mumps Serologies Orchitis without epididymitis should raise concern {or mumps Nephrolithiasis Pain typically starts in flank and Urinalysis Encourage oral intake of Presence of fever or radiates into anterior lower fluids evidence of systemic lmaging abdomen and groin/scrotum as illness should raise (ultrasonography, or Analgesia with NSAIDs stone migrates into lower ureter concern for in{ected noncontrast helical CT) Tamsulosin stone Examination of scrotum and testes are normal Larger stones may require urologic extraction bothersome slirnptoms can be referred for surgical excision of the hydrocele sac. Simple fluid aspiration is usually ineffective because fluid often reaccumulates. Varicoceles occur in L5% to 20"1, of adult men and are caused by dilation of the pampiniform plexus of the sper- matic veins. Symptoms include scrotal swelling and dull and/ or aching pain. On examination, the swelling has a "bag of worms" consistency that becomes smaller with scrotal eleva- tion. Accompanying testicular atrophy may be observed. Although most commonly left-sided, varicoceles can also be right-sided or bilateral. Varicoceles are also associated with male infertility. In patients who are minimally symptomatic with no testicular atrophy, conservative measures (such as NSAIDs and scrotal support) are recommended. For patients with bothersome symptoms or those with testicular atrophy on examination who desire to have children, either surgical ligation (preferred) or percutaneous venous embolization is recommended. Epididymal cysts are soft rounded structures in the head of the epididymis; when Iarger than 2 cm, they are termed spermatoceles. They are usually asymptomatic and require no intervention, but larger painful spermatoceles can be surgi- cally excised.

bothersome slirnptoms can be referred for surgical excision of the hydrocele sac. Simple fluid aspiration is usually ineffective because fluid often reaccumulates. Varicoceles occur in L5% to 20"1, of adult men and are caused by dilation of the pampiniform plexus of the sper- matic veins. Symptoms include scrotal swelling and dull and/ or aching pain. On examination, the swelling has a "bag of worms" consistency that becomes smaller with scrotal eleva- tion. Accompanying testicular atrophy may be observed. Although most commonly left-sided, varicoceles can also be right-sided or bilateral. Varicoceles are also associated with male infertility. In patients who are minimally symptomatic with no testicular atrophy, conservative measures (such as NSAIDs and scrotal support) are recommended. For patients with bothersome symptoms or those with testicular atrophy on examination who desire to have children, either surgical ligation (preferred) or percutaneous venous embolization is recommended. Epididymal cysts are soft rounded structures in the head of the epididymis; when Iarger than 2 cm, they are termed spermatoceles. They are usually asymptomatic and require no intervention, but larger painful spermatoceles can be surgi- cally excised. Acute and Chronic Prostatitis F IG U R E 3. Ultrasound showing a normal testicle (red arow) with a modest- sized hydrocele. Anechoic fluid is visible in the near field; the hydrocele is the and Pelvic Pain entirety of the black area indicated by the b/ue arow. The epididymis(green arrow\ Prostatitis has an estimated prevalence of 9.7o/o. According to is visible, extending left of the testicle. the National Institutes ofHealth consensus classification, there

Acute and Chronic Prostatitis F IG U R E 3. Ultrasound showing a normal testicle (red arow) with a modest- sized hydrocele. Anechoic fluid is visible in the near field; the hydrocele is the and Pelvic Pain entirety of the black area indicated by the b/ue arow. The epididymis(green arrow\ Prostatitis has an estimated prevalence of 9.7o/o. According to is visible, extending left of the testicle. the National Institutes ofHealth consensus classification, there 53

Men's Health TABLE 44. National lnstitute of Health Consensus normal, tender. and/or boggr. In patients $'ith an initially Definition and Classification of Prostatitis negative urine culture, a repeat urine culture obtained after Category Description prostate massage can increase the likelihood of identifuing the causati\€ organism. Antimicrobial therapy is similar to that Acute bacterial prostatitis used for acute bacterial prostatitis and should be guided by Chronic bacteria I prostatitis urine culture results and continued fbr 4 to 6 weeks. ill Chronic prostatitis/chronic pelvic pain More than 9O"/,, of patients with prostatitis have chronic syndrome (A, inflammatory; B, noninflammatory) prostatitis pelvic pain syndrome u,ithout evidence of infection. Asymptomatic infla m matory prostatitis Symptoms vary widely and include chronic urinary symptoms. Data from Krieger JN, Nyberg L Jr, Nickel JC. NIH consensus definition and pelvic pain, and pain with ejaculation. Although there is no classi{ication of prostatitis ILetter]. JAM A 1999;282:236 7 .IPMID: 1042299A) doi:1 0.1 001/jama.282.3.236 clearly established first-line treatment. cr blockers. NSAIDs. and extended courses olantimicrobials with good prostatic tis sue penetration are frequently used. Pharmacotherapl' should are four categories of prostatitis (Table a ). Assessment of not be repeated if no improvement is noted after an initial patients with suspected prostatitis begins with a thorough his- course of appropriate duration. Approximately 30'li, of patients tory including assessment of urinary and systemic symptoms u,ill improve with or without therapy and urologic and sexual history. Vital sign assessment and Asymptomatic inflammatory prostatitis is usually diag abdominal, genital, and digital rectal examinations should be nosed when urologic evaluation is performed for other indica perflormed. Urinalysis and urine culture should be obtained in tions. such as prostate biopsy for an elerated PSA ler,el. The all patients. significance of this form of prostatitis is unclear and. rt'hen Patients with acute bacterial prostatitis typically present present without symptoms. does not require specific therapy. with acute onset of local symptoms (dysuria, urinary fre- quency and urgency, suprapubic andror rectal pain) and sys TEY POIilIS temic symptoms (fevers, chills, nausea,,vomiting, malaise). . Oral ciprofloxacin, levofloxacin, and trimethoprim Digital rectal examination reveals an enlarged, tender, and sulfamethoxazole are options for treating acute bacte- often boggl prostate. Prostate massage may lead to bacteremia rial prostatitis; severely ill patients and those with and should be avoided. Empiric antimicrobial therapy should suspected sepsis should be hospitalized and initially be initiated at time of diagnosis and modified as appropriate treated with parenteral antibiotics. on the basis of urine culture results. Most patients can be man . Although there is no clearly established first line treat- aged with oral agents as outpatients, but severely ill patients ment for chronic pelvic pain syndrome, cr blockers, and those with suspected sepsis should be hospitalized and NSAIDs, and extended courses of antimicrobials with initially treated with parenteral antibiotics (Table 45). good prostatic tissue penetration are frequently used. Antimicrobial agents are typically continued for 2 to 4 weeks; some experts recommend up to 6 weeks. Chronic bacterial prostatitis involves persistent prostate Hernias infection lasting longer than 3 months. It commonly manifests A hemia is a protrusion of tissue through a defect in the sur as recurrent lower urinary tract infections with the same rounding fascia. Inguinal hernias, which account for nearly organism. On digital rectal examination, the prostate may be 75'X, of hernias in men, may be asymptomatic but may present as groin pain and a scrotal or inguinal bulge. lndirect inguinal TABLE 45. Empiric Antimicrobial Therapy for Acute hernias. the most common type, originate at the internal Bacterial Prostatitis inguinal ring, pass through the inguinal canal and external Oral Agents internal ring, and may descend into the scrotum. Direct ingui Trimethoprim-sulfamethoxazole nal hernias originate near the external inguinal ring and usu ally do not descend into the scrotum. Examination may reveal Ciprofloxacin a visible or palpable bulge in the groin or scrotum that is Levofloxacin accentuated by the Valsalva maneuver. Inguinal hernia diagno lntravenous Agents" sis is usually clinical. and imaging studies are rarely needed. Ciprofloxacin or levofloxacin (alone or combined with Small, asymptomatic or minimally symptomatic inguinal gentamycin or tobramycin) hernias may be observed or undergo surgical repair; patients Cefotaxime or ceftazidime (alone or combined with in whom repair is deferred should be advised to seek emergent gentamycin or tobramycin) care if they develop increasing pain or symptoms of bort'el Piperacillin/tazobactam (alone or combined with gentamycin obstruction. Large or bothersome inguinal hernias are usually or tobramycin) repaired surgically. Laparoscopic and open approaches have 'For patients unable to tolerate oral medication or who require hospltalization similar outcomes, but recovery time is shorter for the former. ow ng to severlty of llness Surgical complications of both methods include hematomas,

TABLE 44. National lnstitute of Health Consensus normal, tender. and/or boggr. In patients $'ith an initially Definition and Classification of Prostatitis negative urine culture, a repeat urine culture obtained after Category Description prostate massage can increase the likelihood of identifuing the causati\€ organism. Antimicrobial therapy is similar to that Acute bacterial prostatitis used for acute bacterial prostatitis and should be guided by Chronic bacteria I prostatitis urine culture results and continued fbr 4 to 6 weeks. ill Chronic prostatitis/chronic pelvic pain More than 9O"/,, of patients with prostatitis have chronic syndrome (A, inflammatory; B, noninflammatory) prostatitis pelvic pain syndrome u,ithout evidence of infection. Asymptomatic infla m matory prostatitis Symptoms vary widely and include chronic urinary symptoms. Data from Krieger JN, Nyberg L Jr, Nickel JC. NIH consensus definition and pelvic pain, and pain with ejaculation. Although there is no classi{ication of prostatitis ILetter]. JAM A 1999;282:236 7 .IPMID: 1042299A) doi:1 0.1 001/jama.282.3.236 clearly established first-line treatment. cr blockers. NSAIDs. and extended courses olantimicrobials with good prostatic tis sue penetration are frequently used. Pharmacotherapl' should are four categories of prostatitis (Table a ). Assessment of not be repeated if no improvement is noted after an initial patients with suspected prostatitis begins with a thorough his- course of appropriate duration. Approximately 30'li, of patients tory including assessment of urinary and systemic symptoms u,ill improve with or without therapy and urologic and sexual history. Vital sign assessment and Asymptomatic inflammatory prostatitis is usually diag abdominal, genital, and digital rectal examinations should be nosed when urologic evaluation is performed for other indica perflormed. Urinalysis and urine culture should be obtained in tions. such as prostate biopsy for an elerated PSA ler,el. The all patients. significance of this form of prostatitis is unclear and. rt'hen Patients with acute bacterial prostatitis typically present present without symptoms. does not require specific therapy. with acute onset of local symptoms (dysuria, urinary fre- quency and urgency, suprapubic andror rectal pain) and sys TEY POIilIS temic symptoms (fevers, chills, nausea,,vomiting, malaise). . Oral ciprofloxacin, levofloxacin, and trimethoprim Digital rectal examination reveals an enlarged, tender, and sulfamethoxazole are options for treating acute bacte- often boggl prostate. Prostate massage may lead to bacteremia rial prostatitis; severely ill patients and those with and should be avoided. Empiric antimicrobial therapy should suspected sepsis should be hospitalized and initially be initiated at time of diagnosis and modified as appropriate treated with parenteral antibiotics. on the basis of urine culture results. Most patients can be man . Although there is no clearly established first line treat- aged with oral agents as outpatients, but severely ill patients ment for chronic pelvic pain syndrome, cr blockers, and those with suspected sepsis should be hospitalized and NSAIDs, and extended courses of antimicrobials with initially treated with parenteral antibiotics (Table 45). good prostatic tissue penetration are frequently used. Antimicrobial agents are typically continued for 2 to 4 weeks; some experts recommend up to 6 weeks. Chronic bacterial prostatitis involves persistent prostate Hernias infection lasting longer than 3 months. It commonly manifests A hemia is a protrusion of tissue through a defect in the sur as recurrent lower urinary tract infections with the same rounding fascia. Inguinal hernias, which account for nearly organism. On digital rectal examination, the prostate may be 75'X, of hernias in men, may be asymptomatic but may present as groin pain and a scrotal or inguinal bulge. lndirect inguinal TABLE 45. Empiric Antimicrobial Therapy for Acute hernias. the most common type, originate at the internal Bacterial Prostatitis inguinal ring, pass through the inguinal canal and external Oral Agents internal ring, and may descend into the scrotum. Direct ingui Trimethoprim-sulfamethoxazole nal hernias originate near the external inguinal ring and usu ally do not descend into the scrotum. Examination may reveal Ciprofloxacin a visible or palpable bulge in the groin or scrotum that is Levofloxacin accentuated by the Valsalva maneuver. Inguinal hernia diagno lntravenous Agents" sis is usually clinical. and imaging studies are rarely needed. Ciprofloxacin or levofloxacin (alone or combined with Small, asymptomatic or minimally symptomatic inguinal gentamycin or tobramycin) hernias may be observed or undergo surgical repair; patients Cefotaxime or ceftazidime (alone or combined with in whom repair is deferred should be advised to seek emergent gentamycin or tobramycin) care if they develop increasing pain or symptoms of bort'el Piperacillin/tazobactam (alone or combined with gentamycin obstruction. Large or bothersome inguinal hernias are usually or tobramycin) repaired surgically. Laparoscopic and open approaches have 'For patients unable to tolerate oral medication or who require hospltalization similar outcomes, but recovery time is shorter for the former. ow ng to severlty of llness Surgical complications of both methods include hematomas, 54

Women's Health seromas, and wound infbction. Incarcerated or nonreducible TABTE 46. Breast lmaging Reporting and Data System hernias can be reduced by applying pressure to the area with (Bl-RADS) Assessment Categories the patient in the Trendelenburg position. If the hernia Category 0 Mammography: lncomplete-Need additional remains nonreducible, then surgical evaluation should occur. imaging evaluation and/or prior mammograms for comparison Strangulation of a nonreducible hernia is a surgical emergency because it represents vascular compromise of the entrapped Ultrasound and MRI: lncomplete-Need additional imaging evaluation hernia. Strangulation should be suspected when there is sig nificant tenderness, overlying erythema, and accompanying Category 1 Negative nausea and vomiting. Category 2 Benign Athletic pubalgia (sports hernia) is caused by tearing of Category 3 Probably benign groin muscle fibers and should be suspected in athletes who Category 4 Suspicious participate in high intensity activities and are experiencing Mammography and ultrasound: hernia like symptoms but who have no palpable bulge on Category 4A; Low suspicion for malignancy examination. lnitial treatment consists of rest, physical ther apy, and NSAIDs. Surgery is reserved for those in whom con Category 48: Moderate suspicion for malignancy servative measures fail. Category 4C: High suspicion for malignancy f,EY POITTS Category 5 Highly suggestive of malignancy HVC o Small, asymptomatic or minimally symptomatic ingui- Category 6 Known biopsy-proven malignancy nal hernias may be observed or undergo surgical repair. Reproduced with permission of the American College of Radiology (ACR) {rom o Strangulation of a nonreducible hernia is a surgical D'Orsi CJ, Sickles EA, Mende son EB, et al. ACR Bl RADS' Atlas, Ereast lmagrng Reporting and Data System. Reston, VA, American College of Radiology; 201 3. No emergency and should be suspected when there is sig other representation of this material is authorized without expressed, wriften nificant tenderness, overlying erythema, and accompa- permissionfromtheACR.RefertotheACRwebsiteatwww.acrorg/Clinica Resources/ Reporting and-Data Systems/Bi-Rads for the most current and complete version of nying nausea and vomiting. the Bl RADS' Atlas.

seromas, and wound infbction. Incarcerated or nonreducible TABTE 46. Breast lmaging Reporting and Data System hernias can be reduced by applying pressure to the area with (Bl-RADS) Assessment Categories the patient in the Trendelenburg position. If the hernia Category 0 Mammography: lncomplete-Need additional remains nonreducible, then surgical evaluation should occur. imaging evaluation and/or prior mammograms for comparison Strangulation of a nonreducible hernia is a surgical emergency because it represents vascular compromise of the entrapped Ultrasound and MRI: lncomplete-Need additional imaging evaluation hernia. Strangulation should be suspected when there is sig nificant tenderness, overlying erythema, and accompanying Category 1 Negative nausea and vomiting. Category 2 Benign Athletic pubalgia (sports hernia) is caused by tearing of Category 3 Probably benign groin muscle fibers and should be suspected in athletes who Category 4 Suspicious participate in high intensity activities and are experiencing Mammography and ultrasound: hernia like symptoms but who have no palpable bulge on Category 4A; Low suspicion for malignancy examination. lnitial treatment consists of rest, physical ther apy, and NSAIDs. Surgery is reserved for those in whom con Category 48: Moderate suspicion for malignancy servative measures fail. Category 4C: High suspicion for malignancy f,EY POITTS Category 5 Highly suggestive of malignancy HVC o Small, asymptomatic or minimally symptomatic ingui- Category 6 Known biopsy-proven malignancy nal hernias may be observed or undergo surgical repair. Reproduced with permission of the American College of Radiology (ACR) {rom o Strangulation of a nonreducible hernia is a surgical D'Orsi CJ, Sickles EA, Mende son EB, et al. ACR Bl RADS' Atlas, Ereast lmagrng Reporting and Data System. Reston, VA, American College of Radiology; 201 3. No emergency and should be suspected when there is sig other representation of this material is authorized without expressed, wriften nificant tenderness, overlying erythema, and accompa- permissionfromtheACR.RefertotheACRwebsiteatwww.acrorg/Clinica Resources/ Reporting and-Data Systems/Bi-Rads for the most current and complete version of nying nausea and vomiting. the Bl RADS' Atlas. asymmetric density, or abnormal or pleomorphic calcifications Women's Health potentially indicating breast cancer (see MKSAP 19 Oncologr). For patients with a focal abnormality on clinical examination Breast Symptoms or mammography, targeted ultrasonography can clarit/ the size Breast Mass of the mass, determine whether the mass is solid or cystic, and A palpable breast mass warrants evaluation in all women. identify the margins as smooth or irregular. Ultrasonography is Although breast cancer should be considered in all patients, the preferred method of evaluation for women younger than most breast masses, particularly in women younger than 30 years, in whom mammography has low sensitivity owing to 30 years, are benign conditions, such as cysts, fibroadenomas, dense breasts. lt is also the test ofchoice in pregnant patients. fat necrosis, or lipomas. When breast imaging is completed, results are categorized by Evaluation requires consideration of breast cancer risk using the Breast Imaging Reporting and Data System (BI-RADS) factors, including family history of breast or ovarian cancer, (Table a6). Biopsy is recommended for category 4 and 5 breast previous breast biopsies, hormonal risk factors, and breast findings. Regardless of the BI RADS category any suspicious density, and a detailed history of the mass, including onset, finding on CBE should be evaluated by biopsy, even if no mass changes with the menstrual cycle, associated symptoms, and is identified on imaging. changes in the overlying skin or nipples. In most cases, if a woman requires a biopsy, irn image A clinical breast examination (CBE) should be performed guided core needle biopsy is the most appropriate choice. It is in all women presenting with a breast mass and includes vis important to always perfbrm imaging before biopsy because ual inspection, with attention to any skin changes; palpation biopsy can distort the tissue. For cystic lesions, fine needle of the breast; and palpation of the axillary supraclavicular, aspiration may be appropriate for a simple cyst; however, if and cervical lymph nodes. Findings on CBE may suggest a imaging is convincing for a benign process, aspiration may not benign (smooth, mobile, regular) or a malignant (fixed, hard. be required. Any complex cyst that is BI RADS category 4 or heterogeneous) process. However, the predictive value ofCBE higher should be biopsied rather than aspirated. Management is poor, and all women require further evaluation with imag of an abnormal finding requires consultation with a breast ing and/or biopsy. surgeon. A surgical biopsy is performed when the core needle Imaging of a breast mass may include diagnostic mam biopsy is technically challenging owing to location of the mography and targeted ultrasonography of' the mass. lesion, when atypical hyperplasia is seen on core needle Mammography is the first test performed in most women aged biopsy specimens, or when the pathologr and imaging find- 30 years or older. The mammogram may demonstrate a mass, ings are discordant.

asymmetric density, or abnormal or pleomorphic calcifications Women's Health potentially indicating breast cancer (see MKSAP 19 Oncologr). For patients with a focal abnormality on clinical examination Breast Symptoms or mammography, targeted ultrasonography can clarit/ the size Breast Mass of the mass, determine whether the mass is solid or cystic, and A palpable breast mass warrants evaluation in all women. identify the margins as smooth or irregular. Ultrasonography is Although breast cancer should be considered in all patients, the preferred method of evaluation for women younger than most breast masses, particularly in women younger than 30 years, in whom mammography has low sensitivity owing to 30 years, are benign conditions, such as cysts, fibroadenomas, dense breasts. lt is also the test ofchoice in pregnant patients. fat necrosis, or lipomas. When breast imaging is completed, results are categorized by Evaluation requires consideration of breast cancer risk using the Breast Imaging Reporting and Data System (BI-RADS) factors, including family history of breast or ovarian cancer, (Table a6). Biopsy is recommended for category 4 and 5 breast previous breast biopsies, hormonal risk factors, and breast findings. Regardless of the BI RADS category any suspicious density, and a detailed history of the mass, including onset, finding on CBE should be evaluated by biopsy, even if no mass changes with the menstrual cycle, associated symptoms, and is identified on imaging. changes in the overlying skin or nipples. In most cases, if a woman requires a biopsy, irn image A clinical breast examination (CBE) should be performed guided core needle biopsy is the most appropriate choice. It is in all women presenting with a breast mass and includes vis important to always perfbrm imaging before biopsy because ual inspection, with attention to any skin changes; palpation biopsy can distort the tissue. For cystic lesions, fine needle of the breast; and palpation of the axillary supraclavicular, aspiration may be appropriate for a simple cyst; however, if and cervical lymph nodes. Findings on CBE may suggest a imaging is convincing for a benign process, aspiration may not benign (smooth, mobile, regular) or a malignant (fixed, hard. be required. Any complex cyst that is BI RADS category 4 or heterogeneous) process. However, the predictive value ofCBE higher should be biopsied rather than aspirated. Management is poor, and all women require further evaluation with imag of an abnormal finding requires consultation with a breast ing and/or biopsy. surgeon. A surgical biopsy is performed when the core needle Imaging of a breast mass may include diagnostic mam biopsy is technically challenging owing to location of the mography and targeted ultrasonography of' the mass. lesion, when atypical hyperplasia is seen on core needle Mammography is the first test performed in most women aged biopsy specimens, or when the pathologr and imaging find- 30 years or older. The mammogram may demonstrate a mass, ings are discordant. 55

Women's Health Breast Pain l(tV P0lXTt (ondnucd) Breast pain (mastalgia) is common and may be cyclic or non- o Noncyclic breast pain is usually related to underlying cyclic in relation to the menstrual cycle. Cyclic breast pain is breast conditions; patients with noncyclic focal most common in women aged 20 to 39 years. The pain is often breast pain should be evaluated with age-appropriate diffuse and bilateral, occurs during the premenstrual phase, imaging. and resolves with onset of menstruation; it is usually associ- ated with hormonal changes and is typically benign. Noncyclic breast pain is often caused by medication use (contraceptive Reproductive Health agents, hormone replacement therapy, psychiatric medica- The Centers for Disease Control and Prevention provides tions), underlying breast disease (fibrocystic disease, infec information and recommendations on reproductive health tion, trauma, cancer), or stretching of the Cooper ligaments (www.cdc. gov/reproductirehealth index.html). (connective tissue that maintains breast structural integrity). Nonbreast causes of breast pain include costochondritis, Contraception trauma, coronary artery disease, gastroesophageal reflux dis- Approximately 45"/,, of pregnancies in the United States are ease, and intercostal nerve pain. unintended; the incidence is higher among women of color Evaluation ofbreast pain includes a detailed history to iden and those of low socioeconomic status and is a marker of ti8r characteristics of the pain and its relationship to menses as reproductive health care disparities. Contraception should well as a CBE. Women evaluated for breast pain with no obvious be offered to all women of reproductive potential, particu abnormal findings should be up to date with routine age and risk appropriate breast screening. Women with cyclical pain and larly those with medical conditions that increase risk for pregnancy. Contraception safety based on a woman's indi- a normal CBE do not require additional imaging. Patients with vidual medical comorbidities can be assessed using the CDC noncyclic focal mastalgia u,ho are younger than 30 years should Medical Eligibility Criteria (www.cdc.gov/reproductivehealthi be evaluated with breast ultrasonography, whereas patients contraception/mmwr/mec/summary. html). older than 30 years should undergo diagnostic mammography Contraceptive options include reversible and permanent and breast ultrasonography. Any palpable breast mass should be methods. Table 47 provides a comparison of contraceptive evaluated with diagnostic imaging (see Breast Mass). options. For women with cyclic breast pain and negative clinical findings, conservative management (education, reassurance of the absence of malignancy, advice to wear a supportive and well- Hormonal Contraception fitting brassiere, and topical NSAID therapy) is recommended Combi ne d Hormo nal Cont race ption Combined hormonal (estrogen progesterone) contraception because cyclic pain usually resolves spontaneously. Evidence is (CHC) includes oral contraceptive pills, the transdermal lacking to support limiting caffeine intake or using vitamin E as patch, and the vaginal ring. The use of CHC is associated with a means of mitigating the pain. Medical management may be a decreased risk for endometrial and ovarian cancer and is an offered for patients with severe pain that persists despite con servative management. Danazol is the only FDA-approved agent effective treatment for menorrhagia and dysmenorrhea. CHCs are associated with a small increased risk for venous for cyclic breast pain, but its use is limited by side effects, includ ing amenorrhea, hirsutism, and adverse changes in the lipid thromboembolism (VTE). Contraindications to estrogen profile. Low-dose tamoxifen, although not FDA approved for this progesterone contraceptives include breast cancer, VTE, indication, has been shown to have benefit with fewer side uncontrolled hypertension, liver disease, migraine with aura, effects: however, hot flashes, vaginal dryness, venous thrombo and smoking more than 15 cigarettes a day for women older embolism, and teratogenicity must be considered. Treatment of than 35 years. noncyclic breast pain depends on the underlying cause. Progeste rone Only Contraception I(EY POITTS Progesterone only contraception includes a daily oral pill: . Mammography is the first test performed in most depot medroxyprogesterone acetate injection, which is women aged 30 years or older with a breast mass. administered every 3 months; and the subdermal implant. HVC . Ultrasonography is the preferred method of evaluation A11 methods work by thickening cervical mucus and inhibiting

Breast Pain l(tV P0lXTt (ondnucd) Breast pain (mastalgia) is common and may be cyclic or non- o Noncyclic breast pain is usually related to underlying cyclic in relation to the menstrual cycle. Cyclic breast pain is breast conditions; patients with noncyclic focal most common in women aged 20 to 39 years. The pain is often breast pain should be evaluated with age-appropriate diffuse and bilateral, occurs during the premenstrual phase, imaging. and resolves with onset of menstruation; it is usually associ- ated with hormonal changes and is typically benign. Noncyclic breast pain is often caused by medication use (contraceptive Reproductive Health agents, hormone replacement therapy, psychiatric medica- The Centers for Disease Control and Prevention provides tions), underlying breast disease (fibrocystic disease, infec information and recommendations on reproductive health tion, trauma, cancer), or stretching of the Cooper ligaments (www.cdc. gov/reproductirehealth index.html). (connective tissue that maintains breast structural integrity). Nonbreast causes of breast pain include costochondritis, Contraception trauma, coronary artery disease, gastroesophageal reflux dis- Approximately 45"/,, of pregnancies in the United States are ease, and intercostal nerve pain. unintended; the incidence is higher among women of color Evaluation ofbreast pain includes a detailed history to iden and those of low socioeconomic status and is a marker of ti8r characteristics of the pain and its relationship to menses as reproductive health care disparities. Contraception should well as a CBE. Women evaluated for breast pain with no obvious be offered to all women of reproductive potential, particu abnormal findings should be up to date with routine age and risk appropriate breast screening. Women with cyclical pain and larly those with medical conditions that increase risk for pregnancy. Contraception safety based on a woman's indi- a normal CBE do not require additional imaging. Patients with vidual medical comorbidities can be assessed using the CDC noncyclic focal mastalgia u,ho are younger than 30 years should Medical Eligibility Criteria (www.cdc.gov/reproductivehealthi be evaluated with breast ultrasonography, whereas patients contraception/mmwr/mec/summary. html). older than 30 years should undergo diagnostic mammography Contraceptive options include reversible and permanent and breast ultrasonography. Any palpable breast mass should be methods. Table 47 provides a comparison of contraceptive evaluated with diagnostic imaging (see Breast Mass). options. For women with cyclic breast pain and negative clinical findings, conservative management (education, reassurance of the absence of malignancy, advice to wear a supportive and well- Hormonal Contraception fitting brassiere, and topical NSAID therapy) is recommended Combi ne d Hormo nal Cont race ption Combined hormonal (estrogen progesterone) contraception because cyclic pain usually resolves spontaneously. Evidence is (CHC) includes oral contraceptive pills, the transdermal lacking to support limiting caffeine intake or using vitamin E as patch, and the vaginal ring. The use of CHC is associated with a means of mitigating the pain. Medical management may be a decreased risk for endometrial and ovarian cancer and is an offered for patients with severe pain that persists despite con servative management. Danazol is the only FDA-approved agent effective treatment for menorrhagia and dysmenorrhea. CHCs are associated with a small increased risk for venous for cyclic breast pain, but its use is limited by side effects, includ ing amenorrhea, hirsutism, and adverse changes in the lipid thromboembolism (VTE). Contraindications to estrogen profile. Low-dose tamoxifen, although not FDA approved for this progesterone contraceptives include breast cancer, VTE, indication, has been shown to have benefit with fewer side uncontrolled hypertension, liver disease, migraine with aura, effects: however, hot flashes, vaginal dryness, venous thrombo and smoking more than 15 cigarettes a day for women older embolism, and teratogenicity must be considered. Treatment of than 35 years. noncyclic breast pain depends on the underlying cause. Progeste rone Only Contraception I(EY POITTS Progesterone only contraception includes a daily oral pill: . Mammography is the first test performed in most depot medroxyprogesterone acetate injection, which is women aged 30 years or older with a breast mass. administered every 3 months; and the subdermal implant. HVC . Ultrasonography is the preferred method of evaluation A11 methods work by thickening cervical mucus and inhibiting of a breast mass in women younger than 30 years. olrrlation. There is no increased risk for WE with progestin- o A suspicious breast mass should be evaluated with a only contraception. The progestin based subdermal implant is placed in the biopsy even if imaging results are negative. arm and is approved for 3 years of use. It is the most effective HVC . Cyclic breast pain often occurs in the premenstrual contraceptive option, with a failure rate belo$'0.05'X, at 1 year. phase, tends to be bilateral, and resolves with onset of It is well tolerated but may cause irregular vaginal bleeding; menstruation and conservative management. there is a small risk for infection or hematoma with both (Continued) insertion and removal.

of a breast mass in women younger than 30 years. olrrlation. There is no increased risk for WE with progestin- o A suspicious breast mass should be evaluated with a only contraception. The progestin based subdermal implant is placed in the biopsy even if imaging results are negative. arm and is approved for 3 years of use. It is the most effective HVC . Cyclic breast pain often occurs in the premenstrual contraceptive option, with a failure rate belo$'0.05'X, at 1 year. phase, tends to be bilateral, and resolves with onset of It is well tolerated but may cause irregular vaginal bleeding; menstruation and conservative management. there is a small risk for infection or hematoma with both (Continued) insertion and removal. 56

Women's Health TABLE 47. Comparison of Contraceptive Options Women Experiencing Unintended Pregnancy Within the First Year of Use (o/o) Agent Typical Usea Perfect Use" Advantages Disadvantages Hormonal Contraception Combined hormonal (estrogen-progesterone) contraception Oral contraceptive pill 7 0.3 Easy to use Daily oral pill Transdermal patch 7 0.3 Single patch changed weekly Higher levels of estrogen, increased WE risk Vaginal ring 7 0.3 Ring changed every 3 weeks Progeste ro ne -o n ly contra ce pti on Oral contraceptive pill 7 1 Safe when estrogen is lrregular bleeding, breakthrough contraindicated bleeding Must maintain a daily schedule Depot medroxyproges- 4 0.2 Administered every 3 months lrregular bleeding terone acetate Decreases menstrual frequency Delayed return to fertility (up to 10 mo) Weight gain, decreased bone mineral density Long-acli ng revercible contraception lntrauterine devices Copper 0.8 0.6 Nonhormonal Bleeding and pain with insertion Effective up to 1 0 y Requires office visit for insertion and removal Levonorgestrel 0.1 0.1 Effeaive 3-5 y Decreased menstrual bleeding Progesteronesubdermal 0.05 0.05 Effective up to 3 y lrregular bleeding implant

TABLE 47. Comparison of Contraceptive Options Women Experiencing Unintended Pregnancy Within the First Year of Use (o/o) Agent Typical Usea Perfect Use" Advantages Disadvantages Hormonal Contraception Combined hormonal (estrogen-progesterone) contraception Oral contraceptive pill 7 0.3 Easy to use Daily oral pill Transdermal patch 7 0.3 Single patch changed weekly Higher levels of estrogen, increased WE risk Vaginal ring 7 0.3 Ring changed every 3 weeks Progeste ro ne -o n ly contra ce pti on Oral contraceptive pill 7 1 Safe when estrogen is lrregular bleeding, breakthrough contraindicated bleeding Must maintain a daily schedule Depot medroxyproges- 4 0.2 Administered every 3 months lrregular bleeding terone acetate Decreases menstrual frequency Delayed return to fertility (up to 10 mo) Weight gain, decreased bone mineral density Long-acli ng revercible contraception lntrauterine devices Copper 0.8 0.6 Nonhormonal Bleeding and pain with insertion Effective up to 1 0 y Requires office visit for insertion and removal Levonorgestrel 0.1 0.1 Effeaive 3-5 y Decreased menstrual bleeding Progesteronesubdermal 0.05 0.05 Effective up to 3 y lrregular bleeding implant Topical Sperm lnhibitors Nonoxynol-9(spermicide) 20-30 20-30 On-demand use Vaginal irritation No systemic effects Lactic acid, citric acid, and 14 7 On-demand use Vaginal irritation potassium bitartrate vaginal gel (sperm Nonhormonal Urinary tract infection mobility inhibitor) Barrier Methods Cervicalcap 16-32 9-26 User dependent Vaginal sponge 14-27 9-20 Diaphragm 17 16 Requires spermicide Male condom IJ 5 Protection from STls Female condom zl 2 Protection from STls Permanent Methods Sterilization Female (tubal occlusion) 0.5 0.5 Salpingectomy reduces ovarian lncreased risk for ectopic pregnancy cancer risk Procedural complication (rare) Male (vasectomy) 0.1 5 0.1 Lower cost, fewer complications, Proced ural complication (rare) and more effective than female sterilization

Topical Sperm lnhibitors Nonoxynol-9(spermicide) 20-30 20-30 On-demand use Vaginal irritation No systemic effects Lactic acid, citric acid, and 14 7 On-demand use Vaginal irritation potassium bitartrate vaginal gel (sperm Nonhormonal Urinary tract infection mobility inhibitor) Barrier Methods Cervicalcap 16-32 9-26 User dependent Vaginal sponge 14-27 9-20 Diaphragm 17 16 Requires spermicide Male condom IJ 5 Protection from STls Female condom zl 2 Protection from STls Permanent Methods Sterilization Female (tubal occlusion) 0.5 0.5 Salpingectomy reduces ovarian lncreased risk for ectopic pregnancy cancer risk Procedural complication (rare) Male (vasectomy) 0.1 5 0.1 Lower cost, fewer complications, Proced ural complication (rare) and more effective than female sterilization STI = sexually transmitted infection; VTE = venous thromboembolism. uPerfect use implies correct and consistent use exactly as directed/intended. Typical use reflects rates in actual practice with patients. 57

Women's Health Long- Acting Reu ersible Contraception after unprotected intercourse. Levonorgestrel is available over Long acting reversible contraceptives are highly effective and the counter and is effective in the 3 days after intercourse. It is include intrauterine devices (lUDs) and subdermal implants less effective in overweight women, and women with a BMI (see Progesterone-Only Contraception). An IUD is a small, greater than 26 should use either the copper IUD or ulipristal T-shaped device placed inside the uterus. There are five acetate. FDA-approved IUDs, including one copper device and four levonorgestrel releasing (LNG-IUD) devices. Both types work Preconception Care by preventing fertilization and implantation. The copper IUD Preconception counseling refers to education provided before releases copper ions, which are toxic to sperm; it is FDA pregnancy, aimed at ensuring a healthy pregnancy and reduc- approved for up to 10 years of use. The LNG-IUD inhibits ovu- ing the risk for preterm birth and congenital anomalies. This lation and thickens cervical mucus, obstructing sperrn pene differs from prenatal counseling, which occurs after preg tration; it is FDA approved for 3 to 5 years ofuse, depending on nancy is diagnosed. the brand. It is also highly effective at treating menorrhagia. Any primary care visit for a woman of reproductive age is Changes in menstrual bleeding patterns are the most an oppoftunity to routinely ask whether she would like to common adverse effect. Complications include expulsion (3%, become pregnant in the next year. Women who are not inter 6% in the first year) and uterine perforation (approximately ested in pregnancy should be offered contraception. For 0.1'1, of insertions). Risk for pelvic infection with IUD place- women considering pregnancy, a comprehensive risk assess ment is low and prophylactic antibiotics are not recom ment should be completed (Table 48). An obstetric history of mended during the procedure. If a sexually transmitted gestational hypertension, preeclampsia, or gestational diabetes infection (STI) occurs with an IUD in place, the IUD does not is particularly predictive of future risk. Women at increased need to be removed. Contraindications to IUD placement risk for preeclampsia should be counseled about the use of include pregnancy, anatomic uterine abnormalities with dis- low dose aspirin in pregnancy forprevention. tortion of the uterine cavity, and acute untreated pelvic infection. TABLE 48. Preconception Risk Assessment Risk Category Specific ltems to Assess Barrier Contraception Family planning Desire for pregnancy; number and timing Barrier contraceptive methods, such as diaphragms and con and pregnancy of desired pregnancies; age-related doms, are among the least effective of all the modes of contra spacing changes in fertility, sexuality, contraception ception. Their efficacy is improved when combined with a Exposure to radiation, lead, and mercury Environmental spermicidal agent. Use of either male or female condoms hazards and toxins reduces the risk for STIs. However, the use of spermicide may Nutrition and Healthy diet; folic acid supplementation; increase risk for HIV transmission by disrupting the vaginal folic acid recommended daily intake of iron; epithelial wall. consumption restricting consumption of fish with high mercury levels (e.g., shark, swordfish, king mackerel, and tilefish) Permanent Contraception Genetics Family history of genetic disorders There are several methods of female sterilization. Options include salpingectomy and clipping or electrosurgical desic- Substance use Use of tobacco, alcohol, marijuana, and illicit drugs cation of the fallopian tubes; salpingectomy may be associ Medical Diabetes mellitus, hypertension, thyroid ated with a decreased risk flor ovarian cancer. Women who conditions disease, HIV infection, bariatric surgery, are considering sterilization should be counseled regarding mood disorders, thrombophilia, asthma, procedural risk, the permanency of the method, and the seizure disorder availability of alternative long-acting reversible contraceptive Obstetric history Gestational hypertension, preeclampsia, methods. gestational diabetes Medications Over-the-counter and prescription Emergency Contraception medications, potential teratogens Emergency contraception is contraception using a device or lnfectious Vaccinations up to date; immunity to medication to prevent pregnancy after inadequately protected diseases and varicella and rubella; risk for HIV and vaccinations hepatitis B infection; need for STI intercourse. The most effective form of emergency contracep- screening; potential exposure to Zika virus tion is the placement of a copper IUD within 5 days of inter- Psychosocial Depression, interpersonal/family course, which can reduce the risk for pregnancy by 99'1,,. concerns relationships, exposure to violence, risk Recent data indicate that the 52-mg LNG IUD is noninferior to for abuse (physical, sexual, emotional) the copper IUD for emergency contraception; however, it is STI = sexually transmitted infection. not currently approved for this indication. Two oral contracep lnformation from American College of Obstetricians and Gynecologists. ACOG tive options are ulipristal acetate and levonorgestrel. Ulipristal Committee Opinion No. 762 Summary: Prepregnancy counseling. Obstet Gynecol. 2019;133:228 230. IPMID: 30575672] doi:1 0.1 097IAOG.000000000000301 4 acetate requires a prescription and is elfective for up to 5 days

Long- Acting Reu ersible Contraception after unprotected intercourse. Levonorgestrel is available over Long acting reversible contraceptives are highly effective and the counter and is effective in the 3 days after intercourse. It is include intrauterine devices (lUDs) and subdermal implants less effective in overweight women, and women with a BMI (see Progesterone-Only Contraception). An IUD is a small, greater than 26 should use either the copper IUD or ulipristal T-shaped device placed inside the uterus. There are five acetate. FDA-approved IUDs, including one copper device and four levonorgestrel releasing (LNG-IUD) devices. Both types work Preconception Care by preventing fertilization and implantation. The copper IUD Preconception counseling refers to education provided before releases copper ions, which are toxic to sperm; it is FDA pregnancy, aimed at ensuring a healthy pregnancy and reduc- approved for up to 10 years of use. The LNG-IUD inhibits ovu- ing the risk for preterm birth and congenital anomalies. This lation and thickens cervical mucus, obstructing sperrn pene differs from prenatal counseling, which occurs after preg tration; it is FDA approved for 3 to 5 years ofuse, depending on nancy is diagnosed. the brand. It is also highly effective at treating menorrhagia. Any primary care visit for a woman of reproductive age is Changes in menstrual bleeding patterns are the most an oppoftunity to routinely ask whether she would like to common adverse effect. Complications include expulsion (3%, become pregnant in the next year. Women who are not inter 6% in the first year) and uterine perforation (approximately ested in pregnancy should be offered contraception. For 0.1'1, of insertions). Risk for pelvic infection with IUD place- women considering pregnancy, a comprehensive risk assess ment is low and prophylactic antibiotics are not recom ment should be completed (Table 48). An obstetric history of mended during the procedure. If a sexually transmitted gestational hypertension, preeclampsia, or gestational diabetes infection (STI) occurs with an IUD in place, the IUD does not is particularly predictive of future risk. Women at increased need to be removed. Contraindications to IUD placement risk for preeclampsia should be counseled about the use of include pregnancy, anatomic uterine abnormalities with dis- low dose aspirin in pregnancy forprevention. tortion of the uterine cavity, and acute untreated pelvic infection. TABLE 48. Preconception Risk Assessment Risk Category Specific ltems to Assess Barrier Contraception Family planning Desire for pregnancy; number and timing Barrier contraceptive methods, such as diaphragms and con and pregnancy of desired pregnancies; age-related doms, are among the least effective of all the modes of contra spacing changes in fertility, sexuality, contraception ception. Their efficacy is improved when combined with a Exposure to radiation, lead, and mercury Environmental spermicidal agent. Use of either male or female condoms hazards and toxins reduces the risk for STIs. However, the use of spermicide may Nutrition and Healthy diet; folic acid supplementation; increase risk for HIV transmission by disrupting the vaginal folic acid recommended daily intake of iron; epithelial wall. consumption restricting consumption of fish with high mercury levels (e.g., shark, swordfish, king mackerel, and tilefish) Permanent Contraception Genetics Family history of genetic disorders There are several methods of female sterilization. Options include salpingectomy and clipping or electrosurgical desic- Substance use Use of tobacco, alcohol, marijuana, and illicit drugs cation of the fallopian tubes; salpingectomy may be associ Medical Diabetes mellitus, hypertension, thyroid ated with a decreased risk flor ovarian cancer. Women who conditions disease, HIV infection, bariatric surgery, are considering sterilization should be counseled regarding mood disorders, thrombophilia, asthma, procedural risk, the permanency of the method, and the seizure disorder availability of alternative long-acting reversible contraceptive Obstetric history Gestational hypertension, preeclampsia, methods. gestational diabetes Medications Over-the-counter and prescription Emergency Contraception medications, potential teratogens Emergency contraception is contraception using a device or lnfectious Vaccinations up to date; immunity to medication to prevent pregnancy after inadequately protected diseases and varicella and rubella; risk for HIV and vaccinations hepatitis B infection; need for STI intercourse. The most effective form of emergency contracep- screening; potential exposure to Zika virus tion is the placement of a copper IUD within 5 days of inter- Psychosocial Depression, interpersonal/family course, which can reduce the risk for pregnancy by 99'1,,. concerns relationships, exposure to violence, risk Recent data indicate that the 52-mg LNG IUD is noninferior to for abuse (physical, sexual, emotional) the copper IUD for emergency contraception; however, it is STI = sexually transmitted infection. not currently approved for this indication. Two oral contracep lnformation from American College of Obstetricians and Gynecologists. ACOG tive options are ulipristal acetate and levonorgestrel. Ulipristal Committee Opinion No. 762 Summary: Prepregnancy counseling. Obstet Gynecol. 2019;133:228 230. IPMID: 30575672] doi:1 0.1 097IAOG.000000000000301 4 acetate requires a prescription and is elfective for up to 5 days 58

Women's Health TABLE 49. Commonly Used Medications With Potential information regarding Zika virus and pregnancy (wwr,rr.cdc. for Teratogenic Effects gov I zika I pregnancy/index. html).

Women's Health TABLE 49. Commonly Used Medications With Potential information regarding Zika virus and pregnancy (wwr,rr.cdc. for Teratogenic Effects gov I zika I pregnancy/index. html). Class/Iype Examples Consultation with a genetics counselor may be helpful if Antibiotics there is a personal or family history of genetic disorders. Tetracyclines, sulfonamides, trimethoprim, fluoroquinolones Interventions that optimize pregnancy outcomes Anticoagulants Warfarin, d irect oral anticoagulants include folic acid supplementation (0.+-O.A mg/d Antidepressa nts/ [400 800 pgld]) to reduce the risk for neural tube defects. Lithium mood stabilizers Low dose oral iron supplements can reduce the risk for Antihyperte nsive maternal anemia. Prenatal multivitamins that contain suf ACE inhibitors, angiotensin receptor agents blockers, direct renin inhibitors ficient folic acid are a reasonable option for women contem, Antiepileptic drugs Valproic acid, phenytoin, plating pregnancy. carbamazepine, topiramate Postpartum Care Antithyroid Propylthiou racil, carbimazole, medications methimazole The rise in maternal mortality in the United States over the Hormones past tvvo decades and a shift in etiologz of maternal death, And rogens, testosterone derivatives from obstetric complications to cardiovascular disease, has lm m u nosu ppressanV Folate antagonists, che mothera peutic cyclophosphamide, methotrexate increased the emphasis on high quality postpartum care for agents women. The postpartum period begins after birth and extends Others Vitamin A derivatives, statins, NSAlDs, up to 1 year thereafter. Although women should ideally see isotretinoin their obstetric provider within 12 weeks after delivery up to 40% of women do not attend their immediate postpartum All medications should be reviewed for potential terato- visit. gens (Table 49). In 2015, the FDA published changes in preg- In the postpartum period, women should have a com- nancy and lactation labeling for prescription drugs and prehensive evaluation that involves the assessment of sev- discontinued use ofthe previous letter system for categorizing eral health domains (Table 50). Immediately after birth, risk. Labeling now includes information relevant to the use of postpartum women are at increased risk for multiple health the drug in pregnant and lactating women as well as informa issues, including preeclampsia/eclampsia; VTE; postpartum tion regarding potential risks to females and males of repro- depression; urinary incontinence; and breastfeeding com ductive potential. plications, such as mastitis. The postpartum period is also Physical examination includes assessment of blood pres- an opportunity to assess sexual health and contraceptive sure and BMI. Pelvic examination may be indicated if a woman needs. Birth spacing, with an interval of at least 6 months is due for cervical cancer screening or is experiencing vaginal and ideally more than 18 months between birth and the symptoms. HIV counseling and screening are recommended next pregnancy, is associated with fewer adverse outcomes for all women planning pregnancy. and should be discussed. Thyroid disease, including hyper- Intervention to prevent complications depends on the and hypothyroidism, is common in the year after delivery. risk assessment. A11 women should be encouraged to follow a Women with a history of postpartum thyroiditis should be healthy lifestyle, with emphasis on complete cessation of screened with serum thyroid-stimulating hormone (TSH) tobacco, alcohol, marijuana, or illicit drugs before conception. measurement at 3 and 6 months postpartum and then In addition, they should be encouraged to attain a normal BMI annually. before conception. Women with pregnancy complications, such as gesta Women should be up to date with immunizations. tional diabetes and hypertensive disorders of pregnancy, have Women who are considering pregnancy should be assessed for an increased long term risk for diabetes and cardiovascular immunity to varicella and rubella. For women who are not disease. Women with gestational diabetes require screening immune, varicella and rubella vaccination should be done, with either a fasting blood glucose level or a 2-hour, 75 g oral with the advice that pregnancy be avoided for at least 4 weeks glucose tolerance test between 6 and 12 weeks postpartum after the vaccine is administered to reduce risk to the fetus. and then screening every I to 3 years with a hemoglobin A," Immunizations to be avoided during pregnancy include live level. There are currently no guidelines for management of vaccines (varicella, rubella, measles, mumps, live attenuated women with hypertensive disorders of pregnancy. Women influenza, Iive attenuated herpes zoster) and human papillo with gestational diabetes and hypertensive disorders of preg- mavims vaccine. nancy should be counseled on risk mitigation, including the Patients at potential risk for exposure to infectious dis importance of a healthy lifestyle and achieving a healthy eases, such as Zika virus, should be counseled regarding travel postparlum weight. In addition, they should be monitored restrictions, mode of transmission (including mosquito bites, closely for the development of diabetes and cardiovascular sexual intercourse, and blood transfusion), and timing of disease, with aggressive management of blood pressure to pregnancy after travel. The CDC maintains up-to date prevent future disease.

Class/Iype Examples Consultation with a genetics counselor may be helpful if Antibiotics there is a personal or family history of genetic disorders. Tetracyclines, sulfonamides, trimethoprim, fluoroquinolones Interventions that optimize pregnancy outcomes Anticoagulants Warfarin, d irect oral anticoagulants include folic acid supplementation (0.+-O.A mg/d Antidepressa nts/ [400 800 pgld]) to reduce the risk for neural tube defects. Lithium mood stabilizers Low dose oral iron supplements can reduce the risk for Antihyperte nsive maternal anemia. Prenatal multivitamins that contain suf ACE inhibitors, angiotensin receptor agents blockers, direct renin inhibitors ficient folic acid are a reasonable option for women contem, Antiepileptic drugs Valproic acid, phenytoin, plating pregnancy. carbamazepine, topiramate Postpartum Care Antithyroid Propylthiou racil, carbimazole, medications methimazole The rise in maternal mortality in the United States over the Hormones past tvvo decades and a shift in etiologz of maternal death, And rogens, testosterone derivatives from obstetric complications to cardiovascular disease, has lm m u nosu ppressanV Folate antagonists, che mothera peutic cyclophosphamide, methotrexate increased the emphasis on high quality postpartum care for agents women. The postpartum period begins after birth and extends Others Vitamin A derivatives, statins, NSAlDs, up to 1 year thereafter. Although women should ideally see isotretinoin their obstetric provider within 12 weeks after delivery up to 40% of women do not attend their immediate postpartum All medications should be reviewed for potential terato- visit. gens (Table 49). In 2015, the FDA published changes in preg- In the postpartum period, women should have a com- nancy and lactation labeling for prescription drugs and prehensive evaluation that involves the assessment of sev- discontinued use ofthe previous letter system for categorizing eral health domains (Table 50). Immediately after birth, risk. Labeling now includes information relevant to the use of postpartum women are at increased risk for multiple health the drug in pregnant and lactating women as well as informa issues, including preeclampsia/eclampsia; VTE; postpartum tion regarding potential risks to females and males of repro- depression; urinary incontinence; and breastfeeding com ductive potential. plications, such as mastitis. The postpartum period is also Physical examination includes assessment of blood pres- an opportunity to assess sexual health and contraceptive sure and BMI. Pelvic examination may be indicated if a woman needs. Birth spacing, with an interval of at least 6 months is due for cervical cancer screening or is experiencing vaginal and ideally more than 18 months between birth and the symptoms. HIV counseling and screening are recommended next pregnancy, is associated with fewer adverse outcomes for all women planning pregnancy. and should be discussed. Thyroid disease, including hyper- Intervention to prevent complications depends on the and hypothyroidism, is common in the year after delivery. risk assessment. A11 women should be encouraged to follow a Women with a history of postpartum thyroiditis should be healthy lifestyle, with emphasis on complete cessation of screened with serum thyroid-stimulating hormone (TSH) tobacco, alcohol, marijuana, or illicit drugs before conception. measurement at 3 and 6 months postpartum and then In addition, they should be encouraged to attain a normal BMI annually. before conception. Women with pregnancy complications, such as gesta Women should be up to date with immunizations. tional diabetes and hypertensive disorders of pregnancy, have Women who are considering pregnancy should be assessed for an increased long term risk for diabetes and cardiovascular immunity to varicella and rubella. For women who are not disease. Women with gestational diabetes require screening immune, varicella and rubella vaccination should be done, with either a fasting blood glucose level or a 2-hour, 75 g oral with the advice that pregnancy be avoided for at least 4 weeks glucose tolerance test between 6 and 12 weeks postpartum after the vaccine is administered to reduce risk to the fetus. and then screening every I to 3 years with a hemoglobin A," Immunizations to be avoided during pregnancy include live level. There are currently no guidelines for management of vaccines (varicella, rubella, measles, mumps, live attenuated women with hypertensive disorders of pregnancy. Women influenza, Iive attenuated herpes zoster) and human papillo with gestational diabetes and hypertensive disorders of preg- mavims vaccine. nancy should be counseled on risk mitigation, including the Patients at potential risk for exposure to infectious dis importance of a healthy lifestyle and achieving a healthy eases, such as Zika virus, should be counseled regarding travel postparlum weight. In addition, they should be monitored restrictions, mode of transmission (including mosquito bites, closely for the development of diabetes and cardiovascular sexual intercourse, and blood transfusion), and timing of disease, with aggressive management of blood pressure to pregnancy after travel. The CDC maintains up-to date prevent future disease. 59

Women's Health TABLE 50. The Comprehensive Postpartum Visit l( EY PO I Nl S (continued) Component Clinical Steps . Long-acting reversible contraceptive methods are Physical Assess for perineal or cesarean incision pain highly effective and include intrauterine devices (cop recovery and evidence of incision infection per and levonorgestrel-releasing) as well as a progestin Assess for urinary or fecal incontinence and implant. constipation/hemorrhoids . Women considering pregnancy should undergo a com Provide guidance for return to normal prehensive assessment of risk factors for adverse preg- physical activity and healthy weight nancy outcomes and begin folic acid supplementation. Sexual health Provide guidance on resumption of sexual activity, treatment of dyspareunia, and . Women in the postpartum period should have a com- changes to sexuality plete evaluation, with attention paid to long term risk Assess future reproductive plans, need for for gestational diabetes and hlpertensive disorders of contraception, and importance of birth pregnancy. spacing Psychological Screen for postpartum depression; ensure health appropriate follow-up for women with Menstrual Disorders preexisting mental health disorders Abnormal Uterine Bleeding Screen for tobacco and substance use; provide referrals if indicated Evaluation Abnormal uterine bleeding is defined as excessive bleeding in Assess for social support and intimate partner violence terms of flow volume, frequency, or duration. Among non pregnant women of reproductive age, abnormal uterine bleed Assess sleep and fatigue; offer guidance on management of sleep disruption ing is classified according to etiologz by using the International lnfant care Provide guidance on child sleep practices Federation of Gynaecologr and Obstetrics system with the acronym PALM COEIN (Polyp, Adenomyosis, Leiomyoma, Assess for breastfeeding issues, need for lactation support, and access to breast milk Malignancy and hyperplasia, Coagulopathy, Ovulation dys- pumping supplies function, Endometrial, Iatrogenic, and Not yet classified). Plan for childcare for return to work or Abnormal uterine bleeding in this population can be further school if indicated classified as ovulatory or anovulatory. Ovulatory bleeding is Assess material needs, including housing, accentuation of the cyclic menstrual bleeding. In anovulatory food, utilities, and diapers; referto resources bleeding, the lack of ovulation and cyclic progesterone cause i{ needed irregular bleeding, endometrial hyperplasia, and increased Chronic Discuss future risk of preeclampsia and disease gestational diabetes and risk-mitigation risk for endometrial cancer. Table 51 describes the charac management strategies teristics and causes of abnormal uterine bleeding. Evaluation of abnormal uterine bleeding in the premeno Screen for gestational diabetes pausal woman starts with a detailed history including assess- Review medications for safety during lactation ment of menstrual history and past medical and grnecologic Health Provide immunizations as needed maintenance Screen for cervical cancer as indicated by g uidelines TABLE 51. Classification of Abnormal Uterine Bleeding of Nonpregnant Women of Reproductive Age Recommendations from American College of Obstetricians and Gynecologists. ACOG Committee Opinion No. 736: Optimizing postpartum care. Obstet Gynecol. TyPe Description Associated Causes 20 1 B;1 3 1 :e 1 40 e1 50. IPM ID: 2968391 1 ] dol:1 0.1 097/AOG.0000000000002633 and Paladine HL, Blenning CE, Strangas Y. Postpartum care: an approach to the Ovulatory Occurs at regular Thyroid disease, fou rth trimester. Am Fam Physician. 20 1 9;1 00:485-491 . IPM lD: 3 1 6 1 3576] bleeding interva ls bleeding disorders, structural Menstrualflow is abnormalities (e.g., excessive I(EY POITIS uterine fibroids, polyps, adenomyosis) r Contraception should be offered to all women of repro- Anovulatory lrregular flow and Polycystic ovary ductive potential, particularly those with medical con- bleeding cycle duration syndrome, thyroid ditions that increase risk for pregnancy. diseases, Frequently occurs in . Contraindications to combination estrogen-progesterone the first few years after hyperprolactinem ia, chronic diseases (e.g., menarche and during contraceptives include breast cancer, venous thrombo, chronic liver or kidney perimenopause embolism, uncontrolled hypertension, Iiver disease, disease) migraine with aura, and smoking more than 15 cigarettes Medications (e.g., a day for women older than 35 years. antipsychotic agents, chemotherapy, (Continued) tamoxifen )

Component Clinical Steps . Long-acting reversible contraceptive methods are Physical Assess for perineal or cesarean incision pain highly effective and include intrauterine devices (cop recovery and evidence of incision infection per and levonorgestrel-releasing) as well as a progestin Assess for urinary or fecal incontinence and implant. constipation/hemorrhoids . Women considering pregnancy should undergo a com Provide guidance for return to normal prehensive assessment of risk factors for adverse preg- physical activity and healthy weight nancy outcomes and begin folic acid supplementation. Sexual health Provide guidance on resumption of sexual activity, treatment of dyspareunia, and . Women in the postpartum period should have a com- changes to sexuality plete evaluation, with attention paid to long term risk Assess future reproductive plans, need for for gestational diabetes and hlpertensive disorders of contraception, and importance of birth pregnancy. spacing Psychological Screen for postpartum depression; ensure health appropriate follow-up for women with Menstrual Disorders preexisting mental health disorders Abnormal Uterine Bleeding Screen for tobacco and substance use; provide referrals if indicated Evaluation Abnormal uterine bleeding is defined as excessive bleeding in Assess for social support and intimate partner violence terms of flow volume, frequency, or duration. Among non pregnant women of reproductive age, abnormal uterine bleed Assess sleep and fatigue; offer guidance on management of sleep disruption ing is classified according to etiologz by using the International lnfant care Provide guidance on child sleep practices Federation of Gynaecologr and Obstetrics system with the acronym PALM COEIN (Polyp, Adenomyosis, Leiomyoma, Assess for breastfeeding issues, need for lactation support, and access to breast milk Malignancy and hyperplasia, Coagulopathy, Ovulation dys- pumping supplies function, Endometrial, Iatrogenic, and Not yet classified). Plan for childcare for return to work or Abnormal uterine bleeding in this population can be further school if indicated classified as ovulatory or anovulatory. Ovulatory bleeding is Assess material needs, including housing, accentuation of the cyclic menstrual bleeding. In anovulatory food, utilities, and diapers; referto resources bleeding, the lack of ovulation and cyclic progesterone cause i{ needed irregular bleeding, endometrial hyperplasia, and increased Chronic Discuss future risk of preeclampsia and disease gestational diabetes and risk-mitigation risk for endometrial cancer. Table 51 describes the charac management strategies teristics and causes of abnormal uterine bleeding. Evaluation of abnormal uterine bleeding in the premeno Screen for gestational diabetes pausal woman starts with a detailed history including assess- Review medications for safety during lactation ment of menstrual history and past medical and grnecologic Health Provide immunizations as needed maintenance Screen for cervical cancer as indicated by g uidelines TABLE 51. Classification of Abnormal Uterine Bleeding of Nonpregnant Women of Reproductive Age Recommendations from American College of Obstetricians and Gynecologists. ACOG Committee Opinion No. 736: Optimizing postpartum care. Obstet Gynecol. TyPe Description Associated Causes 20 1 B;1 3 1 :e 1 40 e1 50. IPM ID: 2968391 1 ] dol:1 0.1 097/AOG.0000000000002633 and Paladine HL, Blenning CE, Strangas Y. Postpartum care: an approach to the Ovulatory Occurs at regular Thyroid disease, fou rth trimester. Am Fam Physician. 20 1 9;1 00:485-491 . IPM lD: 3 1 6 1 3576] bleeding interva ls bleeding disorders, structural Menstrualflow is abnormalities (e.g., excessive I(EY POITIS uterine fibroids, polyps, adenomyosis) r Contraception should be offered to all women of repro- Anovulatory lrregular flow and Polycystic ovary ductive potential, particularly those with medical con- bleeding cycle duration syndrome, thyroid ditions that increase risk for pregnancy. diseases, Frequently occurs in . Contraindications to combination estrogen-progesterone the first few years after hyperprolactinem ia, chronic diseases (e.g., menarche and during contraceptives include breast cancer, venous thrombo, chronic liver or kidney perimenopause embolism, uncontrolled hypertension, Iiver disease, disease) migraine with aura, and smoking more than 15 cigarettes Medications (e.g., a day for women older than 35 years. antipsychotic agents, chemotherapy, (Continued) tamoxifen ) 60

Women's Health history. Physical examination should assess for evidence of nausea, vomiting, and diarrhea. Dysmenorrhea is classified as acute bleeding. Pelvic examination can determine the source primary or secondary. Primary dysmenorrhea involves cramp of the bleeding, assess for trauma to the genital track, and look ing lower abdominal and pelvic pain that occurs during for uterine enlargement or irregularity. Initial laboratory test menstrual cycles without an identifiable cause. Secondary ing includes a pregnancy test and complete blood count. dysmenorrhea may result from pelvic conditions, of which Additional testing should be based on clinical indications and endometriosis is the most common. may include coagulation tests, TSH level, iron studies. and A detailed history is necessary to assess the timing of pain hormone levels. and relationship to the menstrual cycle. Sexual history is Transvaginal ultrasonography is often perfbrmed to assess important to assess for infection risk. Primary dysmenorrhea for structural abnormalities and endometrial thickness. can be treated with NSAIDs or contraception, including Endometrial thickness greater than 4 mm in postmenopausal estrogen progesterone and progesterone only methods. women may indicate endometrial hyperplasia or malignancy Secondary dysmenorrhea requires treatment of the underly- i and necessitates biopsy. Proceeding directly to biopsy without ing condition. ultrasound is also a reasonable alternative in postmenopausal I(EY POIilTs women with uterine bleeding. In premenopausal women, endometrial thickness is not a o Evaluation of all patients with abnormal uterine bleed, reliable indicator because thickness varies according to the phase ing includes a detailed history physical and pelvic of the menstrual cycle. Regardless of endometrial thickness, examinations, and pregnancy testing and complete endometrial biopsy should be done in premenopausal women blood count; additional testing should be based on aged 45 years or older or those younger than 45 years who are at clinical indications. increased risk for endometrial cancer secondary to a history of . Risk factors for endometrial cancer include age older unopposed estrogen (polycystic ovary syndrome, obesity); than 45 years; anovulatory bleeding; tamoxifen use; tamoxifen use; Lynch or Cowden syndrome; or reproductive fac- Lynch or Cowden syndrome; obesity; and reproductive tors, such as early menarche, nulliparity, and late menopause. factors, such as early menarche, nulliparity, and late menopause. Treatment o Primary dysmenorrhea can be treated with NSAIDs or Management of abnormal uterine bleeding is aimed at the estrogen-progesterone or progesterone-only methods of underlying cause. Structural abnormalities, such as endome- contraception. trial polyps or submucosal fibroids, may be surgically resected. Treatment of underlying endocrine disorders (thyroid disease, polycystic ovary syndrome) may result in improvement. For women with anovulatory cycles, treatment is aimed Menopause at providing adequate progestin to maintain endometrial sta- Diagnosis bility. The type of therapy depends on the patient's plans for Menopause is the permanent cessation of menses. It is diag contraception. I,br women who wish to preserve fertility, nosed retrospectively after a woman has not experienced a medroxyprogesterone acetate used fbr the second half of the menstrual period for 12 months. Menopause may be natural; menstrual cycle will restore cyclic withdrawal bleeding. For surgical, after bilateral oophorectomy; or medical, as a result women interested in contraception, oral contraceptive pills of such treatments as chemotherapy. Menopause occurring containing estrogen and progesterone, the LNG-IUD, or depot before age 40 years is considered premature menopause or medroxyprogesterone may be used. NSAIDs may also be used premature ovarian insufficiency. Perimenopause refers to the because these drugs reduce synthesis of prostaglandins in the years preceding menopause when ovarian function declines endometrium, leading to vasoconstriction and reduced bleed and is often associated with anovulatory cycles and hot flashes. ing. Tranexamic acid, an antithrombolytic agent, stabilizes Symptoms of menopause include vasomotor symptoms clots and may be used for treatment of heavy vaginal bleeding (hot flashes, night sweats). Hot flashes generally start in the and in women who cannot tolerate hormonal treatment. perimenopausal period and can last lor a few years to lif'elong. For women experiencing acute and severe bleeding, such Women may experience other symptoms, such as depression, agents as gonadotropin-releasing hormone or intravenous anxiety, and irritability, but it is unclear whether these symp administration of high dose estrogens may be used. For toms can be attributed to menopause. Genitourinary syn women who do not respond to medical therapy, operative drome of menopause results from estrogen deficiency and is procedures, such as endometrial ablation, uterine artery characterized by vaginal symptoms, such as burning or irrita embolization, or hysterectomy, may be performed. tion; sexual symptoms, such as dyspareunia or sexual dys function; or urinary symptoms, such as dysuria or recurrent Dysmenorrhea urinary infections. Pelvic examination findings include a pale, Dysmenorrhea is characterized by pain during menstruation; dry vaginal lining with reduction in rugae. Increases in LDL it may also be associated with low back pain, headache, cholesterol and bone loss may also occur (Figure 4).

history. Physical examination should assess for evidence of nausea, vomiting, and diarrhea. Dysmenorrhea is classified as acute bleeding. Pelvic examination can determine the source primary or secondary. Primary dysmenorrhea involves cramp of the bleeding, assess for trauma to the genital track, and look ing lower abdominal and pelvic pain that occurs during for uterine enlargement or irregularity. Initial laboratory test menstrual cycles without an identifiable cause. Secondary ing includes a pregnancy test and complete blood count. dysmenorrhea may result from pelvic conditions, of which Additional testing should be based on clinical indications and endometriosis is the most common. may include coagulation tests, TSH level, iron studies. and A detailed history is necessary to assess the timing of pain hormone levels. and relationship to the menstrual cycle. Sexual history is Transvaginal ultrasonography is often perfbrmed to assess important to assess for infection risk. Primary dysmenorrhea for structural abnormalities and endometrial thickness. can be treated with NSAIDs or contraception, including Endometrial thickness greater than 4 mm in postmenopausal estrogen progesterone and progesterone only methods. women may indicate endometrial hyperplasia or malignancy Secondary dysmenorrhea requires treatment of the underly- i and necessitates biopsy. Proceeding directly to biopsy without ing condition. ultrasound is also a reasonable alternative in postmenopausal I(EY POIilTs women with uterine bleeding. In premenopausal women, endometrial thickness is not a o Evaluation of all patients with abnormal uterine bleed, reliable indicator because thickness varies according to the phase ing includes a detailed history physical and pelvic of the menstrual cycle. Regardless of endometrial thickness, examinations, and pregnancy testing and complete endometrial biopsy should be done in premenopausal women blood count; additional testing should be based on aged 45 years or older or those younger than 45 years who are at clinical indications. increased risk for endometrial cancer secondary to a history of . Risk factors for endometrial cancer include age older unopposed estrogen (polycystic ovary syndrome, obesity); than 45 years; anovulatory bleeding; tamoxifen use; tamoxifen use; Lynch or Cowden syndrome; or reproductive fac- Lynch or Cowden syndrome; obesity; and reproductive tors, such as early menarche, nulliparity, and late menopause. factors, such as early menarche, nulliparity, and late menopause. Treatment o Primary dysmenorrhea can be treated with NSAIDs or Management of abnormal uterine bleeding is aimed at the estrogen-progesterone or progesterone-only methods of underlying cause. Structural abnormalities, such as endome- contraception. trial polyps or submucosal fibroids, may be surgically resected. Treatment of underlying endocrine disorders (thyroid disease, polycystic ovary syndrome) may result in improvement. For women with anovulatory cycles, treatment is aimed Menopause at providing adequate progestin to maintain endometrial sta- Diagnosis bility. The type of therapy depends on the patient's plans for Menopause is the permanent cessation of menses. It is diag contraception. I,br women who wish to preserve fertility, nosed retrospectively after a woman has not experienced a medroxyprogesterone acetate used fbr the second half of the menstrual period for 12 months. Menopause may be natural; menstrual cycle will restore cyclic withdrawal bleeding. For surgical, after bilateral oophorectomy; or medical, as a result women interested in contraception, oral contraceptive pills of such treatments as chemotherapy. Menopause occurring containing estrogen and progesterone, the LNG-IUD, or depot before age 40 years is considered premature menopause or medroxyprogesterone may be used. NSAIDs may also be used premature ovarian insufficiency. Perimenopause refers to the because these drugs reduce synthesis of prostaglandins in the years preceding menopause when ovarian function declines endometrium, leading to vasoconstriction and reduced bleed and is often associated with anovulatory cycles and hot flashes. ing. Tranexamic acid, an antithrombolytic agent, stabilizes Symptoms of menopause include vasomotor symptoms clots and may be used for treatment of heavy vaginal bleeding (hot flashes, night sweats). Hot flashes generally start in the and in women who cannot tolerate hormonal treatment. perimenopausal period and can last lor a few years to lif'elong. For women experiencing acute and severe bleeding, such Women may experience other symptoms, such as depression, agents as gonadotropin-releasing hormone or intravenous anxiety, and irritability, but it is unclear whether these symp administration of high dose estrogens may be used. For toms can be attributed to menopause. Genitourinary syn women who do not respond to medical therapy, operative drome of menopause results from estrogen deficiency and is procedures, such as endometrial ablation, uterine artery characterized by vaginal symptoms, such as burning or irrita embolization, or hysterectomy, may be performed. tion; sexual symptoms, such as dyspareunia or sexual dys function; or urinary symptoms, such as dysuria or recurrent Dysmenorrhea urinary infections. Pelvic examination findings include a pale, Dysmenorrhea is characterized by pain during menstruation; dry vaginal lining with reduction in rugae. Increases in LDL it may also be associated with low back pain, headache, cholesterol and bone loss may also occur (Figure 4). 61

Women's Health TABLE 5?" lnitiating Systemic HormoneTherapyfor Vasomotor Symptoms in Women Younger Than 60 Years or Within 10 Years of Menopause Onseto 1 Step 1 : Confirm that hot flashes/night sw-eats are mod.erate to severe in intensity and are refractory to lifestyle modifications' l Step 2: Assess for contraindications to systemic hormone I therapy. , Step 3: Assess the patient's baseline risk for CVD, WE, and ! breast cancer. For women at increased risk, consider nonhormona I treatments.b I t Step 4: Use the lowest dose of estrogen that relieves I menopausal symptoms. i ! l Step 5: Add systemic progesterone therapy to estrogen therapy 1

menopausal symptoms. i ! l Step 5: Add systemic progesterone therapy to estrogen therapy 1 in women who have an intact uterus. 1 FIGURE 4. Iypical findingsofvaginal atrophy(atrophicvaginitis) indudea pale, Step 6: Assess symptoms and side effects after initiating J l dry vaginal epithelium that is smooth and shiny, with loss of most rugae. therapy and adjust the dose of estrogen if symptoms are I persistent. I Routine laboratory testing for the diagnosis of menopause Step 7: Reassess symptoms and risk factors {or CVD, WE, and l is not recommended. Patients with possible early menopause breast cancer annually. should have pregnancy excluded and undergo measurement Step 8: Discontinue systemic hormone therapy if the risks of of lollicle stimulating hormone, TSH, and prolactin. Younger treatment outweigh the benefits. 1

Routine laboratory testing for the diagnosis of menopause Step 7: Reassess symptoms and risk factors {or CVD, WE, and l is not recommended. Patients with possible early menopause breast cancer annually. should have pregnancy excluded and undergo measurement Step 8: Discontinue systemic hormone therapy if the risks of of lollicle stimulating hormone, TSH, and prolactin. Younger treatment outweigh the benefits. 1 patients should undergo evaluation for amenorrhea (see CVD = cardiovascular disease; VTE = venous thromboembolism MKSAP 19 Endocrinolory and Metabolism). "According to the 20.] 7 hormone therapy position statement of the North American Menopause Society, the safety profile o{ hormone therapy in women who initiate therapy more than 1 0 years after menopause onset or at age 60 years Management or older is not as favorable as for younger women, owing to greater absolute risks for CVD, WE, and breast cancer. It is important to remember that in the perimenopausal bEndocrine Society guidelines recommend that women at high risk Ior CVD, WE, period, pregnancy is possible even if menstrual cycles are or breast cancer consider nonhormonal therapies. For women at moderate risk Ior irregular, and contraception should be discussed if pregnancy CVD or WE who still desire hormone therapy, transdermal estrogen, which has less risk versus oral preparations of estrogen, should be considered. is not desired. Although there is no role for hormone therapy in the prevention of chronic health conditions, it remains the most effective treatment for vasomotor symptoms and may estrogen-only hormone therapy has the lowest risk. All women improve quality of life. Hormone therapy is safest when initi considering hormone therapy should receive individualized ated within 10 years of menopause. breast cancer risk assessment and counseling. Use ofhormone therapy in menopause should be reassessed every year to Vasomotor Symptoms determine benefits and risks. Treatment duration is based on The approach to initiating menopausal hormone therapy for continued presence of vasomotor symptoms. women younger than 60 years or within 10 years of menopause For women who prefer not to use or have contraindica onset is outlined in Table 52. Estrogen is the most effective tions to hormone therapy, nonhormonal drugs can help mod- therapy for vasomotor symptoms; the lowest dose of estrogen ulate vasomotor symptoms. Antidepressant agents, including to manage symptoms should be used. Women who have an selective serotonin reuptake inhibitors (such as citalopram, intact uterus also require progestin either dosed continuously escitalopram, and paroxetine) and serotonin-norepinephrine or cyclically to avoid estrogen-related endometrial prolifera reuptake inhibitors (such as venlafaxine, desvenlafaxine, and tion. Continuous daily estrogen with progestin does not result duloxetine), gabapentin, pregabalin, and clonidine, are effec in cyclic vaginal bleeding, whereas estrogen with cyclic pro tive. Research is inconclusive regarding supplements, such as gestin will result in withdrawal bleeding. Common contrain- soy, black cohosh, and other phytoestrogens, for treating vaso- dications to hormone therapy include pregnancy, unexplained motor symptoms. vaginal bleeding, liver disease, coronary artery disease, stroke, thromboembolic disease. breast cancer. and endometrial can Genitourinary Syndrome of Menopause cer. Adverse events associated with estrogen therapy include Management of genitourinary syndrome of menopause (GSM) cardiovascular disease and VTE. Transdermal estrogen is pref includes topical nonhormonal and hormonal preparations erable to oral estrogen because it is associated with less throm to relieve symptoms. Nonhormonal approaches include as- boembolic risk. needed vaginal lubricants for intercourse and vaginal moistur Use of hormone therapy for more than 1 year has also izers that can alleviate vaginal dryness and irritation when been associated with breast cancer in a dose dependent man used regularly. The North American Menopause Society rec ner; Ionger use results in greater risk. Estrogen with daily ommends nonhormonal vaginal therapies as first-line treat- progestin results in the highest risk for breast cancer, whereas ment for GSM.

patients should undergo evaluation for amenorrhea (see CVD = cardiovascular disease; VTE = venous thromboembolism MKSAP 19 Endocrinolory and Metabolism). "According to the 20.] 7 hormone therapy position statement of the North American Menopause Society, the safety profile o{ hormone therapy in women who initiate therapy more than 1 0 years after menopause onset or at age 60 years Management or older is not as favorable as for younger women, owing to greater absolute risks for CVD, WE, and breast cancer. It is important to remember that in the perimenopausal bEndocrine Society guidelines recommend that women at high risk Ior CVD, WE, period, pregnancy is possible even if menstrual cycles are or breast cancer consider nonhormonal therapies. For women at moderate risk Ior irregular, and contraception should be discussed if pregnancy CVD or WE who still desire hormone therapy, transdermal estrogen, which has less risk versus oral preparations of estrogen, should be considered. is not desired. Although there is no role for hormone therapy in the prevention of chronic health conditions, it remains the most effective treatment for vasomotor symptoms and may estrogen-only hormone therapy has the lowest risk. All women improve quality of life. Hormone therapy is safest when initi considering hormone therapy should receive individualized ated within 10 years of menopause. breast cancer risk assessment and counseling. Use ofhormone therapy in menopause should be reassessed every year to Vasomotor Symptoms determine benefits and risks. Treatment duration is based on The approach to initiating menopausal hormone therapy for continued presence of vasomotor symptoms. women younger than 60 years or within 10 years of menopause For women who prefer not to use or have contraindica onset is outlined in Table 52. Estrogen is the most effective tions to hormone therapy, nonhormonal drugs can help mod- therapy for vasomotor symptoms; the lowest dose of estrogen ulate vasomotor symptoms. Antidepressant agents, including to manage symptoms should be used. Women who have an selective serotonin reuptake inhibitors (such as citalopram, intact uterus also require progestin either dosed continuously escitalopram, and paroxetine) and serotonin-norepinephrine or cyclically to avoid estrogen-related endometrial prolifera reuptake inhibitors (such as venlafaxine, desvenlafaxine, and tion. Continuous daily estrogen with progestin does not result duloxetine), gabapentin, pregabalin, and clonidine, are effec in cyclic vaginal bleeding, whereas estrogen with cyclic pro tive. Research is inconclusive regarding supplements, such as gestin will result in withdrawal bleeding. Common contrain- soy, black cohosh, and other phytoestrogens, for treating vaso- dications to hormone therapy include pregnancy, unexplained motor symptoms. vaginal bleeding, liver disease, coronary artery disease, stroke, thromboembolic disease. breast cancer. and endometrial can Genitourinary Syndrome of Menopause cer. Adverse events associated with estrogen therapy include Management of genitourinary syndrome of menopause (GSM) cardiovascular disease and VTE. Transdermal estrogen is pref includes topical nonhormonal and hormonal preparations erable to oral estrogen because it is associated with less throm to relieve symptoms. Nonhormonal approaches include as- boembolic risk. needed vaginal lubricants for intercourse and vaginal moistur Use of hormone therapy for more than 1 year has also izers that can alleviate vaginal dryness and irritation when been associated with breast cancer in a dose dependent man used regularly. The North American Menopause Society rec ner; Ionger use results in greater risk. Estrogen with daily ommends nonhormonal vaginal therapies as first-line treat- progestin results in the highest risk for breast cancer, whereas ment for GSM. 62

Women's Health Hormonal preparations include estradiol or conjugated Other laboratory testing may include STI testing, complete estrogen in tablet, cream. or ring fbrnrs. Low dose vaginal blood cell count, and type and screen depending on the clini estrogen is recommended for the management of vaginal atro cal scenario. Transvaginal ultrasonography can help diagnosis phy because it builds the vaginal epithelium and restores the ectopic pregnancy, ovarian cysts, ovarian torsion, and tubo acidic pti and microenvironment. Moreover, improving the ovarian abscess as a complication of PID. lining of the lower urethra reduces dysuria and recurrent uri The management of acute pelvic pain depends on the nary tract infection. For women with breast cancer (current or diagnosis. Women with ectopic pregnancies should be evalu past), low-dose vaginal hormone therapy should be given only ated immediately by an obstetrician fbr consideration of' with the approval ofthe treating oncologist. Vaginal dehydro surgical management versus medical management with epiandrosterone and the selective estrogen receptor modulator methotrexate. The treatment ol PID is covered in MKSAP 19 ospemifene are both FDA approved fbr management of dys Inlectious Disease. Gynecologr should be involved in the man pareunia associated with GSM; most experts consider these agement of ovarian cysts, particularly fbr a ruptured hemor treatment modalities second line therapies because of their rhagic cyst in a patient with unstable vital signs and ovarian side effects and limited safety experience. torsion, which is considered a surgical emergency. Appendicitis requires surgical consultation. I(EY POIilT5 HVC . Routine laboratory testing for the diagnosis of meno Chronic Pelvic Pain pause is not recommended; patients with possible early Chronic pelvic pain (CPP) refers to nonmenstn-tal pelvic pain menopause should have pregnancy excluded and of at least 6 months'duration that is severe enough to result in undergo measurement of follicle-stimulating hormone, tunctional disability requiring medical care. Evaluation and thyroid-stimulating hormone, and prolactin. diagnosis of CPP are challenging because it is often rnultifacto . In the perimenopausal period, pregnancy is possible rial and involves both physiologic and psychological compo even if menstrual cycles are irregular, and contraception nents. Risk flactors ftrr CPP include physical, sexual, and/or should be discussed ifpregnancy is not desired. enrotional abusel PID; history of abdominopelvic surgery; . Estrogen is the most effective therapy for vasomotor chronic pain syndromes; and psychological conditions, such symptoms of menopause. as anxiety or depression. Common causes o{ CPP can be classilied as grnecologic, . Nonhormonal options for vasomotor symptoms of gastrointestinal, urologic, and musculoskeletalrneurologic and menopause include antidepressant agents, gabapentin, are outlined in Table 53. pregabalin, and clonidine. Evaluation includes a detailed history to determine char o Management of genitourinary sl,ndrome of menopause acteristics of the pain, including association with menstrual includes topical nonhormonal and hormonal preparations cycle, urination, or bowel movement, as well as assessment fbr to achieve symptom relieL risk factors and known causes of CPP Physical examination includes detailed abdominal and grnecologic examinations. Laboratory testing is of limited value unless specific disorders Pelvic Pain are suggested by the history and clinical examination (such as Acute Pelvic Pain urinalysis for urinary tract infection or STI testing). Although the differential diagnosis of acute pelvic pain is Transvaginal ultrasonography is used to identify anatomic broad, clinicians should consider several critical diagnoses, pathologr, such as a pelvic mass. In the absence of an abnor including ectopic pregnancy, pelvic inflammatory disease mality noted on clinical examination or ultrasound, iaparos (PID), ruptured ovarian cyst, ovarian torsion, and appendicitis, copy may be helpful fbr the evaluation of severe symptoms of' when evaluating a woman with acute pelvic pain. unclear cause to assess for conditions such as endometriosis. History should elicit the characteristics of the pain, Treatment is aimed at the underlying cause and may be including location, radiation, severity, timing, duration, and challenging if no clear cause is identified. Menstrual suppres alleviating and aggravating factors. N4edical history should sion with hormonal contraception can help many patients. note previous abdominal or gznecologic diagnoses or surger Pelvic floor physical therapy, cognitive behavioral therapy. and ies. A sexual history should be obtained for all patients. The sex therapy are recommended. Serotonin-norepinephrine physical examination should focus on vital signs, abdominal reuptake inhibitors, gabapentin, and pregabalin may be help examination, and pelvic examination, specifically a bimanual ful in patients with neuropathic pain. Trigger point injections examination to assess for fundal and adnexal tenderness or should be considered in myofascial chronic pelvic pain. MASSES. Acupuncture and yoga may be helpful tbr some patients. A pregnancy test should be obtained for all women of NSAIDs may be helpful for patients with moderate CPP. reproductive age presenting with acute pelvic pain. Any Routine surgical lysis ofadhesions is not indicated. Peripheral woman with a positive pregnancy test should have ectopic nerve block or surgical release can also be used fbr suspected pregnancy excluded before other diagnoses are considered. nerve impingement or entrapment.

Hormonal preparations include estradiol or conjugated Other laboratory testing may include STI testing, complete estrogen in tablet, cream. or ring fbrnrs. Low dose vaginal blood cell count, and type and screen depending on the clini estrogen is recommended for the management of vaginal atro cal scenario. Transvaginal ultrasonography can help diagnosis phy because it builds the vaginal epithelium and restores the ectopic pregnancy, ovarian cysts, ovarian torsion, and tubo acidic pti and microenvironment. Moreover, improving the ovarian abscess as a complication of PID. lining of the lower urethra reduces dysuria and recurrent uri The management of acute pelvic pain depends on the nary tract infection. For women with breast cancer (current or diagnosis. Women with ectopic pregnancies should be evalu past), low-dose vaginal hormone therapy should be given only ated immediately by an obstetrician fbr consideration of' with the approval ofthe treating oncologist. Vaginal dehydro surgical management versus medical management with epiandrosterone and the selective estrogen receptor modulator methotrexate. The treatment ol PID is covered in MKSAP 19 ospemifene are both FDA approved fbr management of dys Inlectious Disease. Gynecologr should be involved in the man pareunia associated with GSM; most experts consider these agement of ovarian cysts, particularly fbr a ruptured hemor treatment modalities second line therapies because of their rhagic cyst in a patient with unstable vital signs and ovarian side effects and limited safety experience. torsion, which is considered a surgical emergency. Appendicitis requires surgical consultation. I(EY POIilT5 HVC . Routine laboratory testing for the diagnosis of meno Chronic Pelvic Pain pause is not recommended; patients with possible early Chronic pelvic pain (CPP) refers to nonmenstn-tal pelvic pain menopause should have pregnancy excluded and of at least 6 months'duration that is severe enough to result in undergo measurement of follicle-stimulating hormone, tunctional disability requiring medical care. Evaluation and thyroid-stimulating hormone, and prolactin. diagnosis of CPP are challenging because it is often rnultifacto . In the perimenopausal period, pregnancy is possible rial and involves both physiologic and psychological compo even if menstrual cycles are irregular, and contraception nents. Risk flactors ftrr CPP include physical, sexual, and/or should be discussed ifpregnancy is not desired. enrotional abusel PID; history of abdominopelvic surgery; . Estrogen is the most effective therapy for vasomotor chronic pain syndromes; and psychological conditions, such symptoms of menopause. as anxiety or depression. Common causes o{ CPP can be classilied as grnecologic, . Nonhormonal options for vasomotor symptoms of gastrointestinal, urologic, and musculoskeletalrneurologic and menopause include antidepressant agents, gabapentin, are outlined in Table 53. pregabalin, and clonidine. Evaluation includes a detailed history to determine char o Management of genitourinary sl,ndrome of menopause acteristics of the pain, including association with menstrual includes topical nonhormonal and hormonal preparations cycle, urination, or bowel movement, as well as assessment fbr to achieve symptom relieL risk factors and known causes of CPP Physical examination includes detailed abdominal and grnecologic examinations. Laboratory testing is of limited value unless specific disorders Pelvic Pain are suggested by the history and clinical examination (such as Acute Pelvic Pain urinalysis for urinary tract infection or STI testing). Although the differential diagnosis of acute pelvic pain is Transvaginal ultrasonography is used to identify anatomic broad, clinicians should consider several critical diagnoses, pathologr, such as a pelvic mass. In the absence of an abnor including ectopic pregnancy, pelvic inflammatory disease mality noted on clinical examination or ultrasound, iaparos (PID), ruptured ovarian cyst, ovarian torsion, and appendicitis, copy may be helpful fbr the evaluation of severe symptoms of' when evaluating a woman with acute pelvic pain. unclear cause to assess for conditions such as endometriosis. History should elicit the characteristics of the pain, Treatment is aimed at the underlying cause and may be including location, radiation, severity, timing, duration, and challenging if no clear cause is identified. Menstrual suppres alleviating and aggravating factors. N4edical history should sion with hormonal contraception can help many patients. note previous abdominal or gznecologic diagnoses or surger Pelvic floor physical therapy, cognitive behavioral therapy. and ies. A sexual history should be obtained for all patients. The sex therapy are recommended. Serotonin-norepinephrine physical examination should focus on vital signs, abdominal reuptake inhibitors, gabapentin, and pregabalin may be help examination, and pelvic examination, specifically a bimanual ful in patients with neuropathic pain. Trigger point injections examination to assess for fundal and adnexal tenderness or should be considered in myofascial chronic pelvic pain. MASSES. Acupuncture and yoga may be helpful tbr some patients. A pregnancy test should be obtained for all women of NSAIDs may be helpful for patients with moderate CPP. reproductive age presenting with acute pelvic pain. Any Routine surgical lysis ofadhesions is not indicated. Peripheral woman with a positive pregnancy test should have ectopic nerve block or surgical release can also be used fbr suspected pregnancy excluded before other diagnoses are considered. nerve impingement or entrapment. 63

Women's Health TABLE 53. Common Causes of Chronic Pelvic Pain include lack of or significant decrease in interest in sexual Gynecologic Causes activit),. sexual,erotic thoughts or fantasies, excitement or pleasure during sexual activiry and/or initiation ofsexual activ Endometriosis ity or responding to a parlner initiation. Female orgasmic disor- Pelvic adhesions der is characterized by a significant delay in. infrequency of, or Chronic pelvic inflammatory disease absence of orgasm, or significantly decreased intensity of Adenomyosis orgasm during sexual activity. Genitopelvic pain penetration Vulvodynia disorder is characterized by persistent or recurrent dilficultl Ovarian cysts having sexual intercourse; experiencing vulvovaginal or pelvic Uterine (fibroid) pain during intercourse; fear or an-xiety about urlvovaginal or Urologic Causes pelvic pain; and/or tensing or tightening of pelvic floor muscles lnterstitial cystitis/painful bladder syndrome during attempted vaginal penetration. Diagnosis of a sexual dis Radiation cystitis order requires that the symptoms of each disorder occur more than 75'){, oFthe time for at least 6 months and cause clinicallv Urethral syndrome significant distress. Urinary calculi Beyond the three categories of female sex'ual dysfunction. Gastrointestinal Causes \\''omen may erperience sexual dysfunction u,ith and after preg lrritable bowel syndrome nancy. Perinatal events. such as cesarean or instrument delivery lnftammatory bowel disease or perineal tears, may cause pelvic pain. Estrogen levels are lo\\er Chronic constipation during breastfeeding, which may result in vaginal dryness. Diverticulitis Postpartum depression may contribute to decreased sexual desire Celiac disease or frequency. Menopause and GSM may also affect sexual func Musculoskeletal/Neurologic Causes tion because vaginal dryness may contribute to pain $,ith vaginal intercourse. Myofascial pain syndromes When assessing sexual function. it is important to realize Fibromyalgia that sexual functioning involves multiple components. includ Chronic coccygeal pain ing emotions, relationships, past experiences. physiologic Chronic low back pain responses, overall health, and personal beliefs; therefore, a Piriformis syndrome comprehensive approach is needed to evaluate and treat the Neuralgia condition. Assessment of female sexual dysfunction includes detailed f,EY POI ]III questions regarding the patient's sexual and gender identitlr . Women presenting with acute peMc pain should be symptom characteristics. including duration. acute or gradual evaluated for critical diagnoses, including ectopic preg- onset, and ifassociated with a specific partner or a generalized nancy, pelvic inflammatory disease, ruptured ovarian concern; association with painl precipitating events; and level cyst, ovarian torsion, and appendicitis. of distress caused by the symptoms. [n addition. assessment . A pregnancy test should be obtained in all women of should include current lif'e stressors: medical and surgical his tory; medications; and history of physical, emotional. andior reproductive age presenting with acute pelvic pain. sexual abuse. Screening lbr concurrent depression is indicated. o Risk factors for chronic pelvic pain include physical, The Female Sexual Function Index or the Female Sexual sexual, and/or emotional abuse; pelvic inflammatory Distress Scale can be used during the assessment. Pelvic exam- disease; history of abdominopeMc surgery; chronic ination is aimed at assessing for specific sites of pain or tender pain syndromes; Bnd psychological conditions, such as ness. vaginal dryness. or atrophy,. Laboratorl' testing is of anxiety or depression. limited value and is performed only if an underlying cause is suspected. Female Sexual Dysfunction Therapy is aimed at the underlying cause of female sex- Female sexual dysfunction is characterized by persistent or ual dysfunction, which is often multifactorial. There are two recurrent distressing sexual concerns or difficulties and is FDA approved medications for female sexual dysfunction. likely underappreciated. According to the DSM-S, female sex Flibanserin, a serotonin receptor agonist,antagonist, is ual dysfunction is divided into three categories: female sexual approved fbr premenopausal women with female sexual interest/arousal disorder, female orgasmic disorder, and gen interestlarousal disorder without depression. Its use is limited ito-pelvic pain/penetration disorder. secondary to side effects (dizziness, syncope, hypotension, Female sexual interest/arousal disorder is characterized somnolence); incidence of side effects is increased when com by a lack of or signiflcant decrease in sexual activity. This may bined with alcohol or certain medications (antidepressants).

TABLE 53. Common Causes of Chronic Pelvic Pain include lack of or significant decrease in interest in sexual Gynecologic Causes activit),. sexual,erotic thoughts or fantasies, excitement or pleasure during sexual activiry and/or initiation ofsexual activ Endometriosis ity or responding to a parlner initiation. Female orgasmic disor- Pelvic adhesions der is characterized by a significant delay in. infrequency of, or Chronic pelvic inflammatory disease absence of orgasm, or significantly decreased intensity of Adenomyosis orgasm during sexual activity. Genitopelvic pain penetration Vulvodynia disorder is characterized by persistent or recurrent dilficultl Ovarian cysts having sexual intercourse; experiencing vulvovaginal or pelvic Uterine (fibroid) pain during intercourse; fear or an-xiety about urlvovaginal or Urologic Causes pelvic pain; and/or tensing or tightening of pelvic floor muscles lnterstitial cystitis/painful bladder syndrome during attempted vaginal penetration. Diagnosis of a sexual dis Radiation cystitis order requires that the symptoms of each disorder occur more than 75'){, oFthe time for at least 6 months and cause clinicallv Urethral syndrome significant distress. Urinary calculi Beyond the three categories of female sex'ual dysfunction. Gastrointestinal Causes \\''omen may erperience sexual dysfunction u,ith and after preg lrritable bowel syndrome nancy. Perinatal events. such as cesarean or instrument delivery lnftammatory bowel disease or perineal tears, may cause pelvic pain. Estrogen levels are lo\\er Chronic constipation during breastfeeding, which may result in vaginal dryness. Diverticulitis Postpartum depression may contribute to decreased sexual desire Celiac disease or frequency. Menopause and GSM may also affect sexual func Musculoskeletal/Neurologic Causes tion because vaginal dryness may contribute to pain $,ith vaginal intercourse. Myofascial pain syndromes When assessing sexual function. it is important to realize Fibromyalgia that sexual functioning involves multiple components. includ Chronic coccygeal pain ing emotions, relationships, past experiences. physiologic Chronic low back pain responses, overall health, and personal beliefs; therefore, a Piriformis syndrome comprehensive approach is needed to evaluate and treat the Neuralgia condition. Assessment of female sexual dysfunction includes detailed f,EY POI ]III questions regarding the patient's sexual and gender identitlr . Women presenting with acute peMc pain should be symptom characteristics. including duration. acute or gradual evaluated for critical diagnoses, including ectopic preg- onset, and ifassociated with a specific partner or a generalized nancy, pelvic inflammatory disease, ruptured ovarian concern; association with painl precipitating events; and level cyst, ovarian torsion, and appendicitis. of distress caused by the symptoms. [n addition. assessment . A pregnancy test should be obtained in all women of should include current lif'e stressors: medical and surgical his tory; medications; and history of physical, emotional. andior reproductive age presenting with acute pelvic pain. sexual abuse. Screening lbr concurrent depression is indicated. o Risk factors for chronic pelvic pain include physical, The Female Sexual Function Index or the Female Sexual sexual, and/or emotional abuse; pelvic inflammatory Distress Scale can be used during the assessment. Pelvic exam- disease; history of abdominopeMc surgery; chronic ination is aimed at assessing for specific sites of pain or tender pain syndromes; Bnd psychological conditions, such as ness. vaginal dryness. or atrophy,. Laboratorl' testing is of anxiety or depression. limited value and is performed only if an underlying cause is suspected. Female Sexual Dysfunction Therapy is aimed at the underlying cause of female sex- Female sexual dysfunction is characterized by persistent or ual dysfunction, which is often multifactorial. There are two recurrent distressing sexual concerns or difficulties and is FDA approved medications for female sexual dysfunction. likely underappreciated. According to the DSM-S, female sex Flibanserin, a serotonin receptor agonist,antagonist, is ual dysfunction is divided into three categories: female sexual approved fbr premenopausal women with female sexual interest/arousal disorder, female orgasmic disorder, and gen interestlarousal disorder without depression. Its use is limited ito-pelvic pain/penetration disorder. secondary to side effects (dizziness, syncope, hypotension, Female sexual interest/arousal disorder is characterized somnolence); incidence of side effects is increased when com by a lack of or signiflcant decrease in sexual activity. This may bined with alcohol or certain medications (antidepressants). 64

! L I Women's Health i 1 Bremelanotide is a subcutaneous injection approved for use 1 in premenopausal women, but it can only be used eight times t per month and is limited by side effects (skin darkening, nau I sea, vomiting). Off label use of bupropion may improve sex- I ual functioning, although extensive data are lacking. Similarly, low dose testosterone treatment (off-label) increases sexual function scores, but side effects must be discussed and long- term safe[z data are lacking. ln women for whom vaginal i

Bremelanotide is a subcutaneous injection approved for use 1 in premenopausal women, but it can only be used eight times t per month and is limited by side effects (skin darkening, nau I sea, vomiting). Off label use of bupropion may improve sex- I ual functioning, although extensive data are lacking. Similarly, low dose testosterone treatment (off-label) increases sexual function scores, but side effects must be discussed and long- term safe[z data are lacking. ln women for whom vaginal i dryness and atrophy contribute to their symptoms, vaginal . moisturizers and vaginal estrogen therapy may be helpful. Lubricants can be used as needed for intercourse. Pelvic t physical therapy and objects, such as dilators, to increase the diameter of the vagina may be used for patients with vulvo- vaginal pain. Ospemifene is a selective estrogen receptor t I G U R E 5. Clue cells are vaginal epithelial cells whose surface is studded with modulator approved by the FDA lor treatment of dyspareunia adherent coccobacilli bacteria (anowsl, often obscuring the border of the epithelial i associated with vulvovaginal atrophy. cells; they are characteristic of bacterial vaginosis. Treatment strategies must also address the psychological and behavioral aspects of female sexual dysfunction. Cognitive behavioral therapy can help minimize negative attitudes and vaginal pH that contributes to an overgrowth of Gardnerelle help with anxieff. Couples therapy may be beneficial. Sex uaginalis and other anaerobes. Anaerobic overgrowth results therapy includes counseling; cognitive behavioral therapy; in the production of amines, causing the characteristically and treatment of concomitant mental health conditions, such malodorous discharge. Patients with bacterial vaginosis are at as depression and anxiety. increased risk for STIs, including HIV infection, and for pre term delivery. rEY POIl{I More than half of patients with bacterial vaginosis are o Female sexual dysfunction requires a through history asymptomatic. Symptomatic patients report a thin vaginal and physical examination and a comprehensive approach discharge with a fishy odor. Other characteristic findings to treatment addressing physical, psychological, and include a vaginal pH greater than 4.5; a positive whiff test behavioral aspects. result in which application of 10'/. KOH to vaginal secretions results in a fishy odor; and the presence ofclue cells, vaginal epithelial cells that on microscopy have ill-defined cell borders Vaginitis due to adherent coccobacilli (Figure 5). Diagnostic criteria are Vaginitis describes conditions associated with vulvovaginal presented in Table 54. symptoms that may include vaginal discharge, burning, itch- Asymptomatic bacterial vaginosis does not require treat ing, or odor. The most common causes of vaginitis are bacterial ment. Table 54 outlines treatment options for symptomatic vaginosis, candidiasis, and trichomoniasis (Table 54). Other bacterial vaginosis. causes ofvaginitis include irritant vaginitis, allergic vaginitis, and atrophic vaginitis. Normal physiologic vaginal discharge is Vulvovaginal Candidiasis odorless and is not associated with any irritation. Vulvovaginal candidiasis is the second most common cause of History should include details about the vaginal discharge vaginitis; it is usually caused by Candida olbicons and less (volume, color, odor), relation to menstruation, use of douches or commonly by non albicans Candida. Unlike pharyngeal can other products, sexual history dysuria, and dyspareunia. Physical didiasis, it frequently occurs in immunocompetent women examination includes assessment of the lulva and vagina for with no risk factors. Factors that may increase the risk for erythema, edema, excoriation, and discharge. History and physi- vulvovaginal candidiasis include diabetes mellitus, pregnancy, cal examination are insuflicient for diagnosis, and laboratory and use ofglucocorticoids or antibiotics. Recurrent vulvovagi- testing is necessary Diagnostic testing includes assessment of nal candidiasis is categorized as infections occurring four or vaginal pH, amine (whifl) test, and microscopic evaluation with more times per year. saline and potassium hydroxide (KOH) wet mounts. Nucleic acid Vulvovaginal candidiasis is typically characterized by amplication and antigen testing of vaginal discharge is now avail- vaginal itching, irritation, and discharge and may be associ- able to diagnose the common causes of vaginitis. ated with dysuria. Examination reveals vulvar edema and excoriation, with thick, white, curdy vaginal discharge. Bacterial Vaginosis Diagnostic testing involves l0'2, KOH wet mount of the dis- Bacterial vaginosis is the most common cause of vaginitis. It charge showing yeast, hyphae, or pseudohyphae (Figure 6) or results from the loss of the normal hydrogen peroxide- positive nucleic acid amplification test. For recurrent infec producing lactobacilli in the vagina, with an increase in the tions, cultures are important because patients may have an

dryness and atrophy contribute to their symptoms, vaginal . moisturizers and vaginal estrogen therapy may be helpful. Lubricants can be used as needed for intercourse. Pelvic t physical therapy and objects, such as dilators, to increase the diameter of the vagina may be used for patients with vulvo- vaginal pain. Ospemifene is a selective estrogen receptor t I G U R E 5. Clue cells are vaginal epithelial cells whose surface is studded with modulator approved by the FDA lor treatment of dyspareunia adherent coccobacilli bacteria (anowsl, often obscuring the border of the epithelial i associated with vulvovaginal atrophy. cells; they are characteristic of bacterial vaginosis. Treatment strategies must also address the psychological and behavioral aspects of female sexual dysfunction. Cognitive behavioral therapy can help minimize negative attitudes and vaginal pH that contributes to an overgrowth of Gardnerelle help with anxieff. Couples therapy may be beneficial. Sex uaginalis and other anaerobes. Anaerobic overgrowth results therapy includes counseling; cognitive behavioral therapy; in the production of amines, causing the characteristically and treatment of concomitant mental health conditions, such malodorous discharge. Patients with bacterial vaginosis are at as depression and anxiety. increased risk for STIs, including HIV infection, and for pre term delivery. rEY POIl{I More than half of patients with bacterial vaginosis are o Female sexual dysfunction requires a through history asymptomatic. Symptomatic patients report a thin vaginal and physical examination and a comprehensive approach discharge with a fishy odor. Other characteristic findings to treatment addressing physical, psychological, and include a vaginal pH greater than 4.5; a positive whiff test behavioral aspects. result in which application of 10'/. KOH to vaginal secretions results in a fishy odor; and the presence ofclue cells, vaginal epithelial cells that on microscopy have ill-defined cell borders Vaginitis due to adherent coccobacilli (Figure 5). Diagnostic criteria are Vaginitis describes conditions associated with vulvovaginal presented in Table 54. symptoms that may include vaginal discharge, burning, itch- Asymptomatic bacterial vaginosis does not require treat ing, or odor. The most common causes of vaginitis are bacterial ment. Table 54 outlines treatment options for symptomatic vaginosis, candidiasis, and trichomoniasis (Table 54). Other bacterial vaginosis. causes ofvaginitis include irritant vaginitis, allergic vaginitis, and atrophic vaginitis. Normal physiologic vaginal discharge is Vulvovaginal Candidiasis odorless and is not associated with any irritation. Vulvovaginal candidiasis is the second most common cause of History should include details about the vaginal discharge vaginitis; it is usually caused by Candida olbicons and less (volume, color, odor), relation to menstruation, use of douches or commonly by non albicans Candida. Unlike pharyngeal can other products, sexual history dysuria, and dyspareunia. Physical didiasis, it frequently occurs in immunocompetent women examination includes assessment of the lulva and vagina for with no risk factors. Factors that may increase the risk for erythema, edema, excoriation, and discharge. History and physi- vulvovaginal candidiasis include diabetes mellitus, pregnancy, cal examination are insuflicient for diagnosis, and laboratory and use ofglucocorticoids or antibiotics. Recurrent vulvovagi- testing is necessary Diagnostic testing includes assessment of nal candidiasis is categorized as infections occurring four or vaginal pH, amine (whifl) test, and microscopic evaluation with more times per year. saline and potassium hydroxide (KOH) wet mounts. Nucleic acid Vulvovaginal candidiasis is typically characterized by amplication and antigen testing of vaginal discharge is now avail- vaginal itching, irritation, and discharge and may be associ- able to diagnose the common causes of vaginitis. ated with dysuria. Examination reveals vulvar edema and excoriation, with thick, white, curdy vaginal discharge. Bacterial Vaginosis Diagnostic testing involves l0'2, KOH wet mount of the dis- Bacterial vaginosis is the most common cause of vaginitis. It charge showing yeast, hyphae, or pseudohyphae (Figure 6) or results from the loss of the normal hydrogen peroxide- positive nucleic acid amplification test. For recurrent infec producing lactobacilli in the vagina, with an increase in the tions, cultures are important because patients may have an 65

Women's Health TABLE 54. Clinical Presentation, Evaluation, and Management of Vaginitis Cause of Clinical Presentation Evaluation Management Vaginitis Bacterial Malodorous or "fishy" Diagnosis requires three Metronidazole: 500 mg orally twice daily lor 7 d" (avoid vaginosis vaginaldischarge of four findings (Amsel alcohol during treatment and Ior 24 h after last dose), or criteria): vaginal gel (0.75o/o) 5 g into vagina at bedtime for 5 nights lncreased thin white or gray discharge pH >4.5 Clindamycin:vaginal cream (27o) 5 g into vagina for 7 nights Symptoms other than Thin homogenous Secnidazole: 2 g orally as a single dose malodor may be minimal discharge Tinidazole: 1 g orally once daily for 5 d; or 2 g orally once KOH amine whifftest daily for 2 d result positive Clindamycin: 300 mg orally twice daily for 7 d; or 1 00 mg Saline wet mount with ovules into vagina at bedtime for 3 d >20% epithelial clue Notes: Sexual partners do not require treatment cells Avoid sexual activity (or use condoms) during treatment Use oral regimens in pregnancy

TABLE 54. Clinical Presentation, Evaluation, and Management of Vaginitis Cause of Clinical Presentation Evaluation Management Vaginitis Bacterial Malodorous or "fishy" Diagnosis requires three Metronidazole: 500 mg orally twice daily lor 7 d" (avoid vaginosis vaginaldischarge of four findings (Amsel alcohol during treatment and Ior 24 h after last dose), or criteria): vaginal gel (0.75o/o) 5 g into vagina at bedtime for 5 nights lncreased thin white or gray discharge pH >4.5 Clindamycin:vaginal cream (27o) 5 g into vagina for 7 nights Symptoms other than Thin homogenous Secnidazole: 2 g orally as a single dose malodor may be minimal discharge Tinidazole: 1 g orally once daily for 5 d; or 2 g orally once KOH amine whifftest daily for 2 d result positive Clindamycin: 300 mg orally twice daily for 7 d; or 1 00 mg Saline wet mount with ovules into vagina at bedtime for 3 d >20% epithelial clue Notes: Sexual partners do not require treatment cells Avoid sexual activity (or use condoms) during treatment Use oral regimens in pregnancy Vu lvovaginal Itching, irritation, dysuria, pH <4.5 Uncomplicatedb ca ndidiasis dyspareunia, vulvodynia, KOH amine whiff test Fluconazole: 150 mg orally as a single dose excoriation, erythema, result negative fissu res Butoconazole vaginal (2"/" cream)5 g into vagina (single KOH wet mount shows application) lncreased thick white hyphae, pseudohyphae discharge Clotrimazole vaginal: (1% cream)5 g into vagina at or yeast bedtime for 7 -1 4 nights; or 1 00-mg vaginal tablet into vagina at bedtime for 7 nights; or 200 mg (two vaginal tablets) into vagina once daily at bedtime for 3 nights Miconazole vaginal: (27" cream)5 g into vagina at bedtime for 7 nights, or 100-mg vaginal suppository into vagina at bedtime for 7 nights, or 200-mg vaginal suppository into vagina at bedtime for 3 nights Note: Single-dose vaginal preparations and non- imidazoles are available but are less effective Complicated" Longer duration of initial oral or topical treatment, followed by maintenance therapy as needed: Fluconazole: 1 50 mg orally every 3 d {or a total of three doses; or topical imidazole therapy for 7-14 nights Maintenance therapy for refractory or recurrent symptoms: Fluconazole: 150 mg orally weekly for 6 mo Note: Sexual partners do not require treatment Trichomoniasis lncreased discolored KOH amine whiff test Metronidazoleu: 2 g orally as a single dose discharge (yellowish, result negative Tinidazole: 2 g orally as a single dose green, gray, and/or frothy) Saline wet mount with Metronidazole: 500 mg orally twice daily for 7 d Dyspareunia, dysuria, itch, trichomonads, leukocytes erythema, postcoital Notes: Avoid alcohol during treatment and for 24 h alter NAAT or rapid assay bleeding last dose result positive Punctate cervical Treatment of sexual partners is recommended to prevent hemorrhages reinfection ("strawberry" cervix)

Vu lvovaginal Itching, irritation, dysuria, pH <4.5 Uncomplicatedb ca ndidiasis dyspareunia, vulvodynia, KOH amine whiff test Fluconazole: 150 mg orally as a single dose excoriation, erythema, result negative fissu res Butoconazole vaginal (2"/" cream)5 g into vagina (single KOH wet mount shows application) lncreased thick white hyphae, pseudohyphae discharge Clotrimazole vaginal: (1% cream)5 g into vagina at or yeast bedtime for 7 -1 4 nights; or 1 00-mg vaginal tablet into vagina at bedtime for 7 nights; or 200 mg (two vaginal tablets) into vagina once daily at bedtime for 3 nights Miconazole vaginal: (27" cream)5 g into vagina at bedtime for 7 nights, or 100-mg vaginal suppository into vagina at bedtime for 7 nights, or 200-mg vaginal suppository into vagina at bedtime for 3 nights Note: Single-dose vaginal preparations and non- imidazoles are available but are less effective Complicated" Longer duration of initial oral or topical treatment, followed by maintenance therapy as needed: Fluconazole: 1 50 mg orally every 3 d {or a total of three doses; or topical imidazole therapy for 7-14 nights Maintenance therapy for refractory or recurrent symptoms: Fluconazole: 150 mg orally weekly for 6 mo Note: Sexual partners do not require treatment Trichomoniasis lncreased discolored KOH amine whiff test Metronidazoleu: 2 g orally as a single dose discharge (yellowish, result negative Tinidazole: 2 g orally as a single dose green, gray, and/or frothy) Saline wet mount with Metronidazole: 500 mg orally twice daily for 7 d Dyspareunia, dysuria, itch, trichomonads, leukocytes erythema, postcoital Notes: Avoid alcohol during treatment and for 24 h alter NAAT or rapid assay bleeding last dose result positive Punctate cervical Treatment of sexual partners is recommended to prevent hemorrhages reinfection ("strawberry" cervix) KOH = potasslum hydroxide; NAAT= nucleic acld amp ification test.

Vu lvovaginal Itching, irritation, dysuria, pH <4.5 Uncomplicatedb ca ndidiasis dyspareunia, vulvodynia, KOH amine whiff test Fluconazole: 150 mg orally as a single dose excoriation, erythema, result negative fissu res Butoconazole vaginal (2"/" cream)5 g into vagina (single KOH wet mount shows application) lncreased thick white hyphae, pseudohyphae discharge Clotrimazole vaginal: (1% cream)5 g into vagina at or yeast bedtime for 7 -1 4 nights; or 1 00-mg vaginal tablet into vagina at bedtime for 7 nights; or 200 mg (two vaginal tablets) into vagina once daily at bedtime for 3 nights Miconazole vaginal: (27" cream)5 g into vagina at bedtime for 7 nights, or 100-mg vaginal suppository into vagina at bedtime for 7 nights, or 200-mg vaginal suppository into vagina at bedtime for 3 nights Note: Single-dose vaginal preparations and non- imidazoles are available but are less effective Complicated" Longer duration of initial oral or topical treatment, followed by maintenance therapy as needed: Fluconazole: 1 50 mg orally every 3 d {or a total of three doses; or topical imidazole therapy for 7-14 nights Maintenance therapy for refractory or recurrent symptoms: Fluconazole: 150 mg orally weekly for 6 mo Note: Sexual partners do not require treatment Trichomoniasis lncreased discolored KOH amine whiff test Metronidazoleu: 2 g orally as a single dose discharge (yellowish, result negative Tinidazole: 2 g orally as a single dose green, gray, and/or frothy) Saline wet mount with Metronidazole: 500 mg orally twice daily for 7 d Dyspareunia, dysuria, itch, trichomonads, leukocytes erythema, postcoital Notes: Avoid alcohol during treatment and for 24 h alter NAAT or rapid assay bleeding last dose result positive Punctate cervical Treatment of sexual partners is recommended to prevent hemorrhages reinfection ("strawberry" cervix) KOH = potasslum hydroxide; NAAT= nucleic acld amp ification test. "Safe in pregnancy. bUncomplicated vulvovaginal candidiasis: Candida albicans, mild to moderate symptom severity, healthy nonpregnant women, four or fewer episodes per year.

Vu lvovaginal Itching, irritation, dysuria, pH <4.5 Uncomplicatedb ca ndidiasis dyspareunia, vulvodynia, KOH amine whiff test Fluconazole: 150 mg orally as a single dose excoriation, erythema, result negative fissu res Butoconazole vaginal (2"/" cream)5 g into vagina (single KOH wet mount shows application) lncreased thick white hyphae, pseudohyphae discharge Clotrimazole vaginal: (1% cream)5 g into vagina at or yeast bedtime for 7 -1 4 nights; or 1 00-mg vaginal tablet into vagina at bedtime for 7 nights; or 200 mg (two vaginal tablets) into vagina once daily at bedtime for 3 nights Miconazole vaginal: (27" cream)5 g into vagina at bedtime for 7 nights, or 100-mg vaginal suppository into vagina at bedtime for 7 nights, or 200-mg vaginal suppository into vagina at bedtime for 3 nights Note: Single-dose vaginal preparations and non- imidazoles are available but are less effective Complicated" Longer duration of initial oral or topical treatment, followed by maintenance therapy as needed: Fluconazole: 1 50 mg orally every 3 d {or a total of three doses; or topical imidazole therapy for 7-14 nights Maintenance therapy for refractory or recurrent symptoms: Fluconazole: 150 mg orally weekly for 6 mo Note: Sexual partners do not require treatment Trichomoniasis lncreased discolored KOH amine whiff test Metronidazoleu: 2 g orally as a single dose discharge (yellowish, result negative Tinidazole: 2 g orally as a single dose green, gray, and/or frothy) Saline wet mount with Metronidazole: 500 mg orally twice daily for 7 d Dyspareunia, dysuria, itch, trichomonads, leukocytes erythema, postcoital Notes: Avoid alcohol during treatment and for 24 h alter NAAT or rapid assay bleeding last dose result positive Punctate cervical Treatment of sexual partners is recommended to prevent hemorrhages reinfection ("strawberry" cervix) KOH = potasslum hydroxide; NAAT= nucleic acld amp ification test. "Safe in pregnancy. bUncomplicated vulvovaginal candidiasis: Candida albicans, mild to moderate symptom severity, healthy nonpregnant women, four or fewer episodes per year. mellitus, or immunosuppression. Only topical azo e therapres, applied for 7 days, are recommended for use among pregnant women.

KOH = potasslum hydroxide; NAAT= nucleic acld amp ification test. "Safe in pregnancy. bUncomplicated vulvovaginal candidiasis: Candida albicans, mild to moderate symptom severity, healthy nonpregnant women, four or fewer episodes per year. mellitus, or immunosuppression. Only topical azo e therapres, applied for 7 days, are recommended for use among pregnant women. TreatmentregimensfromtheCDCSexuallyTransmitted n{ectionsGuidelinesathttps://www.cdc.gov/std/tg2015/default.htm.AccessedJone17,2021. 65

Eye Disorders l( EY P 011{ TS konttnucd) o Diagnostic testing for vulvovaginal candidiasis involves l0'2, potassium hydroxide wet mount showing yeast, hyphae, or pseudohlphae. . Nucleic acid amplification testing (NAAT) and antigen testing are routinely available to diagnose bacterial vagi- nosis and'"ulvovaginal candidiasis; NAAT is the preferred diagnostic test for trichomoniasis.

l( EY P 011{ TS konttnucd) o Diagnostic testing for vulvovaginal candidiasis involves l0'2, potassium hydroxide wet mount showing yeast, hyphae, or pseudohlphae. . Nucleic acid amplification testing (NAAT) and antigen testing are routinely available to diagnose bacterial vagi- nosis and'"ulvovaginal candidiasis; NAAT is the preferred diagnostic test for trichomoniasis. Eye Disorders t I G U R E 6. Candida vaginitis showing buddin g yeast (b/u e arrow\,spores lblack Eye Emergencies arrow\, and elongated spores appearing as pseudohyphae ( red arrow)with lnternists must accurately diagnose conditions that can cause potassium hydroxide. permanent vision loss and require immediate ophthalmologic evaluation (Table 55). infection with a non-albicans Condidc species requiring dif Patients with periocular trauma and potential globe ferent treatment. injury should undergo visual acuity assessment and anterior Asymptomatic patients should not receive treatment. See eye segment evaluation with either a penlight or slit lamp. Table 5,1 for treatment options for symptomatic uncomplicated Findings that suggest globe rupture include pupil deviation and complicated vulvovaginal candidiasis. Recurrent symp- toward the laceration site, anterior chamber depth loss and toms after treatment warrant an evaluation for underlying blood collection (hyphema) (Figure 7), and subconjunctival predisposing Factors. l-remorrhage completely surrounding the cornea. Patients witl.r suspected globe injury should not undergo tonometry Trichomoniasis or pupil dilation and should have an eye shield placed over Trichomoniasis is a vaginal infection caused by Trichomonos the af'fected eye. When globe injury occurs or there is uncer uoginolis. a flagellated protozoan, and is a sexually trans tainty about globe integrity, emergent referral to ophthalmol mitted infection. It is associated with increased risk for ogr is indicated. preterm labor in pregnancy as well as increased risk for HIV Chemical injury to the eyes causes decreased vision, eye transmission. pair-r and burning, foreign body sensation, and tearing. Women may be asymptomatic or present with copious Examination may reveal eyelid swelling and erythema, con vaginal discharge that is malodorous; pale yellow, green, or gray; junctival injection, blepharospasm, and corneal defect. Eye fiothy; and associated with vulval itching and burning. Vaginal irrigation with normal saline or lactated Ringer solution pH is often elevated, but this is not helpful diagnostically. Although microscopy with examination of a wet mount of the vaginal fluid showing motile trichon-ronads can be diagnostic, TABLE 55. Selected Eye Conditions Requiring lmmediate Ophthalmologic Evaluation the CDC recommends nucleic acid amplification testing. When Trichontonas is identifled, testing lor other STIs should be con Acute angle-closure glaucoma

Eye Disorders t I G U R E 6. Candida vaginitis showing buddin g yeast (b/u e arrow\,spores lblack Eye Emergencies arrow\, and elongated spores appearing as pseudohyphae ( red arrow)with lnternists must accurately diagnose conditions that can cause potassium hydroxide. permanent vision loss and require immediate ophthalmologic evaluation (Table 55). infection with a non-albicans Condidc species requiring dif Patients with periocular trauma and potential globe ferent treatment. injury should undergo visual acuity assessment and anterior Asymptomatic patients should not receive treatment. See eye segment evaluation with either a penlight or slit lamp. Table 5,1 for treatment options for symptomatic uncomplicated Findings that suggest globe rupture include pupil deviation and complicated vulvovaginal candidiasis. Recurrent symp- toward the laceration site, anterior chamber depth loss and toms after treatment warrant an evaluation for underlying blood collection (hyphema) (Figure 7), and subconjunctival predisposing Factors. l-remorrhage completely surrounding the cornea. Patients witl.r suspected globe injury should not undergo tonometry Trichomoniasis or pupil dilation and should have an eye shield placed over Trichomoniasis is a vaginal infection caused by Trichomonos the af'fected eye. When globe injury occurs or there is uncer uoginolis. a flagellated protozoan, and is a sexually trans tainty about globe integrity, emergent referral to ophthalmol mitted infection. It is associated with increased risk for ogr is indicated. preterm labor in pregnancy as well as increased risk for HIV Chemical injury to the eyes causes decreased vision, eye transmission. pair-r and burning, foreign body sensation, and tearing. Women may be asymptomatic or present with copious Examination may reveal eyelid swelling and erythema, con vaginal discharge that is malodorous; pale yellow, green, or gray; junctival injection, blepharospasm, and corneal defect. Eye fiothy; and associated with vulval itching and burning. Vaginal irrigation with normal saline or lactated Ringer solution pH is often elevated, but this is not helpful diagnostically. Although microscopy with examination of a wet mount of the vaginal fluid showing motile trichon-ronads can be diagnostic, TABLE 55. Selected Eye Conditions Requiring lmmediate Ophthalmologic Evaluation the CDC recommends nucleic acid amplification testing. When Trichontonas is identifled, testing lor other STIs should be con Acute angle-closure glaucoma sidered. See Table 54 for treatment of trichomoniasis. Women Cenlral retinal artery occlusion should be retested within 3 months of treatment. Treatment of Central retinal vein occlusion sexual partners is recommended to prevent reinfection. Chemical injury l(EY POt l{rS Corneal ulcers

sidered. See Table 54 for treatment of trichomoniasis. Women Cenlral retinal artery occlusion should be retested within 3 months of treatment. Treatment of Central retinal vein occlusion sexual partners is recommended to prevent reinfection. Chemical injury l(EY POt l{rS Corneal ulcers HVC . Clinical findings do not sufficiently distinguish between Endophtha lm itis the common causes of vaginitis, and laboratory testing Hyperacute bacterial conjunctivitis is necessary to establish a diagnosis in bacterial vaginitis Ke ratiti s or trichomoniasis. Optic neuritis o Characteristic findings of bacterialvaginosis includes a Orbitalcellulitis thin vaginal discharge, vaginal pH greater than 4.5, a Retinal detachment positive whiff test result in which application of 10% Scleritis potassium hydroxide to vaginal secretions results in a fishy odor, and the presence ofclue cells. Trauma (Continued) Uveitis 67